Provider Demographics
NPI:1376986802
Name:ROOT, LISA (PSYD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:ROOT
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:442 HAGELBARGER AVE
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99712-1917
Mailing Address - Country:US
Mailing Address - Phone:907-350-4353
Mailing Address - Fax:
Practice Address - Street 1:442 HAGELBARGER AVE
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99712-1917
Practice Address - Country:US
Practice Address - Phone:907-350-4353
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-15
Last Update Date:2013-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO012375101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health