Provider Demographics
NPI:1043788466
Name:ELLERMAN, LISA (MED, LPC)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:ELLERMAN
Suffix:
Gender:F
Credentials:MED, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8114 SPINNAKER CV
Mailing Address - Street 2:
Mailing Address - City:ROWLETT
Mailing Address - State:TX
Mailing Address - Zip Code:75089-2526
Mailing Address - Country:US
Mailing Address - Phone:972-523-4964
Mailing Address - Fax:214-299-9146
Practice Address - Street 1:1111 BELT LINE RD
Practice Address - Street 2:
Practice Address - City:GARLAND
Practice Address - State:TX
Practice Address - Zip Code:75040-3299
Practice Address - Country:US
Practice Address - Phone:972-961-7078
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-03
Last Update Date:2021-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX75916101Y00000X, 101YP2500X
VT75916101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health