Provider Demographics
NPI:1003172206
Name:WILLIAMS, LISA JOHANNA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:JOHANNA
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:432 PRATER WAY
Mailing Address - Street 2:
Mailing Address - City:SPARKS
Mailing Address - State:NV
Mailing Address - Zip Code:89431-4528
Mailing Address - Country:US
Mailing Address - Phone:775-376-2149
Mailing Address - Fax:
Practice Address - Street 1:63 KEYSTONE AVE STE 304
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89503-5524
Practice Address - Country:US
Practice Address - Phone:775-333-5222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-02
Last Update Date:2012-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1780899724Medicaid