Provider Demographics
NPI:1124586664
Name:CANNISTRACI, LISA LOUISE (CO 60716486)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:LOUISE
Last Name:CANNISTRACI
Suffix:
Gender:F
Credentials:CO 60716486
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 545
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:WA
Mailing Address - Zip Code:98236-0545
Mailing Address - Country:US
Mailing Address - Phone:360-341-4451
Mailing Address - Fax:
Practice Address - Street 1:31640 STATE ROUTE 20
Practice Address - Street 2:
Practice Address - City:OAK HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98277-3128
Practice Address - Country:US
Practice Address - Phone:360-679-7676
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-04
Last Update Date:2019-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO60716486101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)