Provider Demographics
NPI:1568534923
Name:HERGERT, LISA (MS CLINICAL THERAPIS)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:HERGERT
Suffix:
Gender:F
Credentials:MS CLINICAL THERAPIS
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:HERGERT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 887
Mailing Address - Street 2:
Mailing Address - City:MARSHFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:54449-0887
Mailing Address - Country:US
Mailing Address - Phone:715-384-7579
Mailing Address - Fax:
Practice Address - Street 1:252 S CENTRAL AVE
Practice Address - Street 2:SUITE #21
Practice Address - City:MARSHFIELD
Practice Address - State:WI
Practice Address - Zip Code:54449-2843
Practice Address - Country:US
Practice Address - Phone:715-384-7579
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3557101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39672800Medicaid
WI42245000Medicaid