Provider Demographics
NPI:1174832547
Name:SHOUP, LISA M (LDAC)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:SHOUP
Suffix:
Gender:F
Credentials:LDAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4321 41ST ST
Mailing Address - Street 2:PO BOX 1028
Mailing Address - City:COLUMBUS
Mailing Address - State:NE
Mailing Address - Zip Code:68601-9414
Mailing Address - Country:US
Mailing Address - Phone:402-562-8952
Mailing Address - Fax:402-564-0611
Practice Address - Street 1:4321 41ST ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:NE
Practice Address - Zip Code:68601-9414
Practice Address - Country:US
Practice Address - Phone:402-562-8952
Practice Address - Fax:402-564-0611
Is Sole Proprietor?:No
Enumeration Date:2010-10-01
Last Update Date:2015-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE875101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)