Provider Demographics
NPI:1073724233
Name:BLAKEN-MILLER, LISA MARIE (LPC)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:MARIE
Last Name:BLAKEN-MILLER
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N9710 STATE HWY 108
Mailing Address - Street 2:
Mailing Address - City:MELROSE
Mailing Address - State:WI
Mailing Address - Zip Code:54642-8258
Mailing Address - Country:US
Mailing Address - Phone:608-386-1086
Mailing Address - Fax:608-488-2161
Practice Address - Street 1:N9710 STATE HWY 108
Practice Address - Street 2:
Practice Address - City:MELROSE
Practice Address - State:WI
Practice Address - Zip Code:54642-8258
Practice Address - Country:US
Practice Address - Phone:608-386-1086
Practice Address - Fax:608-488-2161
Is Sole Proprietor?:No
Enumeration Date:2007-05-26
Last Update Date:2014-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3289125101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health