Provider Demographics
NPI:1205031002
Name:POTTORF, LISA STAIRES (MED, LPC)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:STAIRES
Last Name:POTTORF
Suffix:
Gender:F
Credentials:MED, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4525 S. IRVINGTON AVE.
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74135
Mailing Address - Country:US
Mailing Address - Phone:918-832-7764
Mailing Address - Fax:918-832-7765
Practice Address - Street 1:4528 S SHERIDAN RD STE 117
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74145-1101
Practice Address - Country:US
Practice Address - Phone:918-794-6570
Practice Address - Fax:918-340-5189
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-20
Last Update Date:2012-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2224101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health