Provider Demographics
NPI:1386196863
Name:KING, LISA C (MA, NLC)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:C
Last Name:KING
Suffix:
Gender:F
Credentials:MA, NLC
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:TRISTAO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:220 RUSKIN DR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80910-2522
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:875 W MORENO AVE
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80905-1731
Practice Address - Country:US
Practice Address - Phone:719-572-6100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-31
Last Update Date:2016-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CONLC.0012502101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health