Provider Demographics
NPI:1518103399
Name:SLADE, LISA MICHELLE (LPC)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:MICHELLE
Last Name:SLADE
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:72 READ ST
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06607-2016
Mailing Address - Country:US
Mailing Address - Phone:203-368-2769
Mailing Address - Fax:
Practice Address - Street 1:1115 MAIN ST STE 702
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06604-4406
Practice Address - Country:US
Practice Address - Phone:203-334-5500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-27
Last Update Date:2008-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0001781101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional