Provider Demographics
NPI:1548591878
Name:PENDLETON, LISA (MS)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:PENDLETON
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2001 S SHIELDS ST
Mailing Address - Street 2:BUILDING D, STE 203
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80526-1827
Mailing Address - Country:US
Mailing Address - Phone:970-493-4580
Mailing Address - Fax:970-493-4580
Practice Address - Street 1:4115 BOARDWALK DR
Practice Address - Street 2:SUITE 100
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-5945
Practice Address - Country:US
Practice Address - Phone:970-493-4580
Practice Address - Fax:970-797-2859
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-27
Last Update Date:2016-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO10267106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist