Provider Demographics
NPI:1134672975
Name:BARGENDER, LISA T (LCSW, CSAC)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:T
Last Name:BARGENDER
Suffix:
Gender:F
Credentials:LCSW, CSAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2514 LENNON ST
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:WI
Mailing Address - Zip Code:53901-1125
Mailing Address - Country:US
Mailing Address - Phone:608-843-4800
Mailing Address - Fax:
Practice Address - Street 1:505 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:BARABOO
Practice Address - State:WI
Practice Address - Zip Code:53913-2183
Practice Address - Country:US
Practice Address - Phone:608-355-4200
Practice Address - Fax:608-355-4299
Is Sole Proprietor?:No
Enumeration Date:2016-07-28
Last Update Date:2022-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI18096101YA0400X
WI130020-121104100000X
WI89671041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100058771Medicaid