Provider Demographics
NPI:1104401074
Name:FRYETT, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:FRYETT
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 1:3204 123RD ST SE
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98208-6123
Mailing Address - Country:US
Mailing Address - Phone:425-876-5472
Mailing Address - Fax:
Practice Address - Street 1:2601 SUMMIT AVE
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-3309
Practice Address - Country:US
Practice Address - Phone:425-876-5472
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-12
Last Update Date:2021-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health