Provider Demographics
NPI:1134470545
Name:DECLARK, LISA MARY
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARY
Last Name:DECLARK
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 1:119 W 2ND ST
Mailing Address - Street 2:
Mailing Address - City:PERRYSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43551-1402
Mailing Address - Country:US
Mailing Address - Phone:419-376-6059
Mailing Address - Fax:
Practice Address - Street 1:119 W 2ND ST
Practice Address - Street 2:
Practice Address - City:PERRYSBURG
Practice Address - State:OH
Practice Address - Zip Code:43551-1402
Practice Address - Country:US
Practice Address - Phone:419-376-6059
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-25
Last Update Date:2016-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE.1100125101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health