Provider Demographics
NPI:1609129576
Name:PAGE, LISA H (LMHC)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:H
Last Name:PAGE
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1726 KINGSLEY AVE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-4463
Mailing Address - Country:US
Mailing Address - Phone:904-278-5644
Mailing Address - Fax:904-278-5659
Practice Address - Street 1:3292 COUNTY ROAD 220
Practice Address - Street 2:
Practice Address - City:MIDDLEBURG
Practice Address - State:FL
Practice Address - Zip Code:32068-4357
Practice Address - Country:US
Practice Address - Phone:904-278-5644
Practice Address - Fax:904-278-5659
Is Sole Proprietor?:No
Enumeration Date:2012-10-17
Last Update Date:2012-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH10467101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLMH10467Medicaid