Provider Demographics
NPI:1275903288
Name:FADORSEN, LISA (LMHC)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:FADORSEN
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9478
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34206-9478
Mailing Address - Country:US
Mailing Address - Phone:941-782-4299
Mailing Address - Fax:941-782-4301
Practice Address - Street 1:2020 26TH AVE E
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34208-7753
Practice Address - Country:US
Practice Address - Phone:941-782-4600
Practice Address - Fax:941-782-4601
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-02
Last Update Date:2018-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE1200017101YP2500X
FLPMH1252101YP2500X
MS1198101YP2500X
FLMH15099101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional