Provider Demographics
NPI:1477019974
Name:RICHARDSON, LISA R (LMHC, LPC, NBCC)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:R
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:LMHC, LPC, NBCC
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:R
Other - Last Name:WILLIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC, NBCC
Mailing Address - Street 1:1607 LARCHWOOD DR
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34293-1016
Mailing Address - Country:US
Mailing Address - Phone:941-882-0590
Mailing Address - Fax:
Practice Address - Street 1:1505 TAMIAMI TRL S STE 402
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34285-5563
Practice Address - Country:US
Practice Address - Phone:941-882-0590
Practice Address - Fax:941-444-0602
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-20
Last Update Date:2019-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001923101YP2500X
FLMH11228101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional