Provider Demographics
NPI:1073061610
Name:RIST, LISA (MA, LPC-I)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:RIST
Suffix:
Gender:F
Credentials:MA, LPC-I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 SOUTH MAIN ST SUITE C
Mailing Address - Street 2:
Mailing Address - City:MAULDIN
Mailing Address - State:SC
Mailing Address - Zip Code:29662
Mailing Address - Country:US
Mailing Address - Phone:864-371-2853
Mailing Address - Fax:866-808-0926
Practice Address - Street 1:400 SOUTH MAIN ST SUITE C
Practice Address - Street 2:
Practice Address - City:MAULDIN
Practice Address - State:SC
Practice Address - Zip Code:29662
Practice Address - Country:US
Practice Address - Phone:864-371-2853
Practice Address - Fax:866-808-0926
Is Sole Proprietor?:No
Enumeration Date:2016-09-12
Last Update Date:2019-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6748101YM0800X
SC6298101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health