Provider Demographics
NPI:1154824761
Name:MCCLINTON, LISA MICHELE
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MICHELE
Last Name:MCCLINTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:MICHELE
Other - Last Name:TALLY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1212 MONTGOMERY BLVD
Mailing Address - Street 2:
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70461-4414
Mailing Address - Country:US
Mailing Address - Phone:504-717-6979
Mailing Address - Fax:
Practice Address - Street 1:1212 MONTGOMERY BLVD
Practice Address - Street 2:
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70461
Practice Address - Country:US
Practice Address - Phone:504-717-6979
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-10
Last Update Date:2018-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA101YM0800X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty