Provider Demographics
NPI:1376001743
Name:OWSLEY, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:OWSLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 E 19TH ST N
Mailing Address - Street 2:
Mailing Address - City:BIG STONE GAP
Mailing Address - State:VA
Mailing Address - Zip Code:24219-3468
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:205 E 19TH ST N
Practice Address - Street 2:
Practice Address - City:BIG STONE GAP
Practice Address - State:VA
Practice Address - Zip Code:24219-3468
Practice Address - Country:US
Practice Address - Phone:276-644-7690
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-05
Last Update Date:2019-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701007235101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional