Provider Demographics
NPI:1114656139
Name:DOMONKOS-SLAMA, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:DOMONKOS-SLAMA
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 1:11319 S FAIRWAY RIDGE LN
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99224-8378
Mailing Address - Country:US
Mailing Address - Phone:509-413-8467
Mailing Address - Fax:
Practice Address - Street 1:11319 S FAIRWAY RIDGE LN
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99224-8378
Practice Address - Country:US
Practice Address - Phone:509-413-8467
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-06
Last Update Date:2023-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMC61428019101YM0800X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health