Provider Demographics
NPI:1164294096
Name:YOUNG, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:YOUNG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:FLEMING
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LASAC
Mailing Address - Street 1:2830 W DIANA AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85051-4050
Mailing Address - Country:US
Mailing Address - Phone:602-299-6293
Mailing Address - Fax:520-796-3884
Practice Address - Street 1:3850 N 16TH ST
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85226
Practice Address - Country:US
Practice Address - Phone:520-796-3832
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-24
Last Update Date:2023-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ13315101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)