Provider Demographics
NPI:1043739410
Name:KILGORE, LISA M
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:KILGORE
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 1:1609 BRITISH WAY
Mailing Address - Street 2:
Mailing Address - City:VINTON
Mailing Address - State:VA
Mailing Address - Zip Code:24179-6076
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10 WALNUT AVE STE 3
Practice Address - Street 2:
Practice Address - City:VINTON
Practice Address - State:VA
Practice Address - Zip Code:24179-2537
Practice Address - Country:US
Practice Address - Phone:540-798-1210
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-16
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional