Provider Demographics
NPI:1154670610
Name:CAMERON, LISA BARTHOLOMEW (LAC)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:BARTHOLOMEW
Last Name:CAMERON
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:LYNN
Other - Last Name:BARTHOLOMEW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 9859
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58106-9859
Mailing Address - Country:US
Mailing Address - Phone:701-451-4900
Mailing Address - Fax:651-925-0057
Practice Address - Street 1:2701 12TH AVE S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-8753
Practice Address - Country:US
Practice Address - Phone:701-451-4900
Practice Address - Fax:651-925-0057
Is Sole Proprietor?:No
Enumeration Date:2012-08-30
Last Update Date:2021-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1686101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)