Provider Demographics
NPI:1275135972
Name:ELLISON, LISA MARIE (MA, LMT)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:ELLISON
Suffix:
Gender:F
Credentials:MA, LMT
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:MARIE
Other - Last Name:KLINGELHOEFER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1665 LAKE CHRISTOPHER DR
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23464-7805
Mailing Address - Country:US
Mailing Address - Phone:724-601-3027
Mailing Address - Fax:
Practice Address - Street 1:900 GRANBY ST
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23510-2503
Practice Address - Country:US
Practice Address - Phone:757-447-0931
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-09
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0019013803225700000X
101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist