Provider Demographics
NPI:1023362944
Name:RUNZO, LISA M (MA, LPC, LMFT)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:M
Last Name:RUNZO
Suffix:
Gender:F
Credentials:MA, LPC, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5360 N ACADEMY BLVD
Mailing Address - Street 2:SUITE 130
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80918-4006
Mailing Address - Country:US
Mailing Address - Phone:719-695-0757
Mailing Address - Fax:
Practice Address - Street 1:5360 N ACADEMY BLVD
Practice Address - Street 2:SUITE 130
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80918-4006
Practice Address - Country:US
Practice Address - Phone:719-227-7477
Practice Address - Fax:719-227-7474
Is Sole Proprietor?:No
Enumeration Date:2012-10-30
Last Update Date:2016-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COMFT.0001193106H00000X
COLPC.0012170101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO12665446OtherCAQH