Provider Demographics
NPI:1265837363
Name:ANSELL, LISA MARIE (ED D)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:ANSELL
Suffix:
Gender:F
Credentials:ED D
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:MARIE
Other - Last Name:CORNWELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1845
Mailing Address - Street 2:
Mailing Address - City:GRANDBY
Mailing Address - State:CO
Mailing Address - Zip Code:80446-1845
Mailing Address - Country:US
Mailing Address - Phone:970-509-0321
Mailing Address - Fax:
Practice Address - Street 1:195 N. 3RD STREET
Practice Address - Street 2:
Practice Address - City:GRANBY
Practice Address - State:CO
Practice Address - Zip Code:80446
Practice Address - Country:US
Practice Address - Phone:970-509-0321
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-31
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
COLPC.0014645101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000184658Medicaid