Provider Demographics
NPI:1578656211
Name:HENRIKSEN, LISA MARIE (MD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:MARIE
Last Name:HENRIKSEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:5000 W NATIONAL AVE
Mailing Address - Street 2:DEPT OF PSYCHIATRY
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53295-0001
Mailing Address - Country:US
Mailing Address - Phone:414-384-2000
Mailing Address - Fax:414-382-5379
Practice Address - Street 1:5000 W NATIONAL AVE
Practice Address - Street 2:DEPT OF PSYCHIATRY
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53295-0001
Practice Address - Country:US
Practice Address - Phone:414-384-2000
Practice Address - Fax:414-382-5379
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2014-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI45710-20207Q00000X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34439000Medicaid