Provider Demographics
NPI:1164672473
Name:NELSON, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:NELSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:SAMPSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS
Mailing Address - Street 1:890 RINEYVILLE RD
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42701-8927
Mailing Address - Country:US
Mailing Address - Phone:270-234-0577
Mailing Address - Fax:270-234-8367
Practice Address - Street 1:890 RINEYVILLE RD
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-8927
Practice Address - Country:US
Practice Address - Phone:270-234-0577
Practice Address - Fax:270-234-8367
Is Sole Proprietor?:No
Enumeration Date:2008-09-23
Last Update Date:2008-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY123103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical