Provider Demographics
NPI:1578080743
Name:MOEN, LISA (MA)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:
Last Name:MOEN
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:ZYLSTRA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7525 MITCHELL RD STE 100
Mailing Address - Street 2:
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55344-1900
Mailing Address - Country:US
Mailing Address - Phone:952-224-2282
Mailing Address - Fax:952-224-2284
Practice Address - Street 1:1833 3RD AVE
Practice Address - Street 2:
Practice Address - City:ANOKA
Practice Address - State:MN
Practice Address - Zip Code:55303-2424
Practice Address - Country:US
Practice Address - Phone:763-421-5535
Practice Address - Fax:763-433-0226
Is Sole Proprietor?:No
Enumeration Date:2017-08-28
Last Update Date:2020-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
MNLP6538103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health