Provider Demographics
NPI:1407265929
Name:FANN, LISA (LMHC)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:FANN
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:444 NE RAVENNA BLVD STE 301
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98115-6467
Mailing Address - Country:US
Mailing Address - Phone:206-784-5005
Mailing Address - Fax:
Practice Address - Street 1:109 N 101ST ST
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98133-9109
Practice Address - Country:US
Practice Address - Phone:206-784-5005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-08
Last Update Date:2014-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH 60092174101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health