Provider Demographics
NPI:1548419716
Name:POLO, LISA A (MED,LPC)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:A
Last Name:POLO
Suffix:
Gender:F
Credentials:MED,LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2206 90TH AVENUE
Mailing Address - Street 2:
Mailing Address - City:BALDWIN
Mailing Address - State:WI
Mailing Address - Zip Code:54002-3222
Mailing Address - Country:US
Mailing Address - Phone:715-688-4913
Mailing Address - Fax:
Practice Address - Street 1:900 6TH ST N STE 104
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:WI
Practice Address - Zip Code:54016-7172
Practice Address - Country:US
Practice Address - Phone:715-688-9178
Practice Address - Fax:715-688-4916
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-12
Last Update Date:2009-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3794-125101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43743400Medicaid