Provider Demographics
NPI:1205021896
Name:LOPEZ, LISA TATUM (MA, LMHC, CMHS)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:TATUM
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:MA, LMHC, CMHS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15408 MAIN ST UNIT 107
Mailing Address - Street 2:
Mailing Address - City:MILL CREEK
Mailing Address - State:WA
Mailing Address - Zip Code:98012-9025
Mailing Address - Country:US
Mailing Address - Phone:425-772-7234
Mailing Address - Fax:425-377-0785
Practice Address - Street 1:15408 MAIN ST UNIT 107
Practice Address - Street 2:
Practice Address - City:MILL CREEK
Practice Address - State:WA
Practice Address - Zip Code:98012-9025
Practice Address - Country:US
Practice Address - Phone:425-772-7234
Practice Address - Fax:425-377-0785
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-07
Last Update Date:2011-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH60237309101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health