Provider Demographics
NPI:1578691200
Name:FARRELL, LISA (LC)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:FARRELL
Suffix:
Gender:F
Credentials:LC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 73511
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99707-3511
Mailing Address - Country:US
Mailing Address - Phone:907-451-8208
Mailing Address - Fax:
Practice Address - Street 1:626 2ND ST STE 102
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-3466
Practice Address - Country:US
Practice Address - Phone:907-388-0105
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-02
Last Update Date:2020-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK2487101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health