Provider Demographics
NPI:1346028008
Name:SROK, LISA MICHELLE (LGPC, ATR-P, MA)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MICHELLE
Last Name:SROK
Suffix:
Gender:F
Credentials:LGPC, ATR-P, MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16811 RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:UPPERCO
Mailing Address - State:MD
Mailing Address - Zip Code:21155-9461
Mailing Address - Country:US
Mailing Address - Phone:423-326-5524
Mailing Address - Fax:
Practice Address - Street 1:3600 CLIPPER MILL RD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21211-1948
Practice Address - Country:US
Practice Address - Phone:423-326-5524
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-14
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGP15008101YP2500X
23-316221700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist