Provider Demographics
NPI:1609872589
Name:SQUIRE, LISA SHARON (PHD, LP)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:SHARON
Last Name:SQUIRE
Suffix:
Gender:F
Credentials:PHD, LP
Other - Prefix:DR
Other - First Name:LISA
Other - Middle Name:S
Other - Last Name:SQUIRE PHD LP
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD LP
Mailing Address - Street 1:7800 METRO PKWY
Mailing Address - Street 2:STE 300
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55425-1509
Mailing Address - Country:US
Mailing Address - Phone:952-854-2440
Mailing Address - Fax:952-854-2465
Practice Address - Street 1:7800 METRO PKWY
Practice Address - Street 2:STE 300
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55425-1509
Practice Address - Country:US
Practice Address - Phone:952-854-2440
Practice Address - Fax:952-854-2465
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-24
Last Update Date:2015-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNMNLP0204103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN680001602Medicare PIN