Provider Demographics
NPI:1154305126
Name:HARDESTY, LISA R (PHD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:R
Last Name:HARDESTY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:R
Other - Last Name:CLEMENSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1025 MARSH ST
Mailing Address - Street 2:
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001-4752
Mailing Address - Country:US
Mailing Address - Phone:507-625-4031
Mailing Address - Fax:
Practice Address - Street 1:1695 LOR RAY DR
Practice Address - Street 2:
Practice Address - City:NORTH MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56003-2804
Practice Address - Country:US
Practice Address - Phone:507-387-8231
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-02
Last Update Date:2020-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3904103TB0200X
MNLP3904103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN680001287Medicare UPIN