Provider Demographics
NPI:1114660644
Name:BRACKEN, LISA MARIE
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:BRACKEN
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 1:640 FREEDOM BUSINESS CTR DR STE 220
Mailing Address - Street 2:
Mailing Address - City:KING OF PRUSSIA
Mailing Address - State:PA
Mailing Address - Zip Code:19406-1376
Mailing Address - Country:US
Mailing Address - Phone:484-965-9966
Mailing Address - Fax:484-231-8631
Practice Address - Street 1:209 W LANCASTER AVE STE 100
Practice Address - Street 2:
Practice Address - City:PAOLI
Practice Address - State:PA
Practice Address - Zip Code:19301-1749
Practice Address - Country:US
Practice Address - Phone:484-965-9966
Practice Address - Fax:484-231-8631
Is Sole Proprietor?:No
Enumeration Date:2022-04-13
Last Update Date:2022-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PABCBA-1-21-53071103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst