Provider Demographics
NPI:1295830107
Name:LISA, MARTHA W (MED)
Entity Type:Individual
Prefix:MRS
First Name:MARTHA
Middle Name:W
Last Name:LISA
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1879 LEE RD
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32789-2102
Mailing Address - Country:US
Mailing Address - Phone:407-599-7141
Mailing Address - Fax:407-679-1567
Practice Address - Street 1:1879 LEE RD
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32789-2102
Practice Address - Country:US
Practice Address - Phone:407-599-7141
Practice Address - Fax:407-679-1567
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLZ1792OtherBC/BS OF FLORIDA