Provider Demographics
NPI:1568498467
Name:VANTRIEST-PEADEN, LISA (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:
Last Name:VANTRIEST-PEADEN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MRS
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:VANTRIEST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:2100 N BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74820-1048
Mailing Address - Country:US
Mailing Address - Phone:580-436-7120
Mailing Address - Fax:580-436-7121
Practice Address - Street 1:2100 N BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820-1048
Practice Address - Country:US
Practice Address - Phone:580-436-7120
Practice Address - Fax:580-436-7121
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2008-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK29651041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK231427405Medicare ID - Type Unspecified