Provider Demographics
NPI:1376684597
Name:WHITE, LISA LYNN (MSW LCSW)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:LYNN
Last Name:WHITE
Suffix:
Gender:F
Credentials:MSW LCSW
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:WHITE PC
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1751 S 8TH ST
Mailing Address - Street 2:
Mailing Address - City:CO SPGS
Mailing Address - State:CO
Mailing Address - Zip Code:80906
Mailing Address - Country:US
Mailing Address - Phone:719-471-1816
Mailing Address - Fax:719-471-9987
Practice Address - Street 1:1751 S 8TH ST
Practice Address - Street 2:
Practice Address - City:CO SPGS
Practice Address - State:CO
Practice Address - Zip Code:80906
Practice Address - Country:US
Practice Address - Phone:719-471-1816
Practice Address - Fax:719-471-9987
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2021-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO989114103T00000X
1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO035526Medicaid