Provider Demographics
NPI:1114086410
Name:VONDERHAAR, LISA MARET (PHD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:MARET
Last Name:VONDERHAAR
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10291 CHIPPEWA CIR
Mailing Address - Street 2:
Mailing Address - City:SALIDA
Mailing Address - State:CO
Mailing Address - Zip Code:81201-9596
Mailing Address - Country:US
Mailing Address - Phone:970-531-0574
Mailing Address - Fax:
Practice Address - Street 1:10291 CHIPPEWA CIR
Practice Address - Street 2:
Practice Address - City:SALIDA
Practice Address - State:CO
Practice Address - Zip Code:81201-9596
Practice Address - Country:US
Practice Address - Phone:970-531-0574
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2022-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2106103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
COCOA101010Medicare PIN