Provider Demographics
NPI:1417218363
Name:PANTANO, LISA (MC, LPC)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:PANTANO
Suffix:
Gender:F
Credentials:MC, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1009 DE LA VISTA PL
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80911-2400
Mailing Address - Country:US
Mailing Address - Phone:719-465-7879
Mailing Address - Fax:
Practice Address - Street 1:411 LAKEWOOD CIR STE C201
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80910-2668
Practice Address - Country:US
Practice Address - Phone:719-465-7879
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-06
Last Update Date:2016-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX69130101YP2500X
COLPC0011875101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional