Provider Demographics
NPI:1114095429
Name:RICHARDSON, LISA (MSS, LICSW)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:MSS, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:988 CHEROKEE AVE
Mailing Address - Street 2:
Mailing Address - City:WEST SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55118-1111
Mailing Address - Country:US
Mailing Address - Phone:651-552-4694
Mailing Address - Fax:
Practice Address - Street 1:1821 UNIVERSITY AVE W
Practice Address - Street 2:STE. N-464
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-2887
Practice Address - Country:US
Practice Address - Phone:651-659-2900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN174121041C0700X
CT0041711041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical