Provider Demographics
NPI:1033139456
Name:OSVOLD, LISE LEIGH (PHD, LP)
Entity Type:Individual
Prefix:DR
First Name:LISE
Middle Name:LEIGH
Last Name:OSVOLD
Suffix:
Gender:F
Credentials:PHD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:913 W SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27603-2159
Mailing Address - Country:US
Mailing Address - Phone:919-787-1240
Mailing Address - Fax:919-787-1241
Practice Address - Street 1:5500 MCNEELY DR
Practice Address - Street 2:SUITE 101
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27612-7623
Practice Address - Country:US
Practice Address - Phone:919-787-1240
Practice Address - Fax:919-787-1241
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2675103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6000547Medicaid
NC2819895CMedicare ID - Type UnspecifiedLISE OSVOLD THE PRACTITIO