Provider Demographics
NPI:1619219904
Name:HAROLDSON, LIZA
Entity Type:Individual
Prefix:
First Name:LIZA
Middle Name:
Last Name:HAROLDSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LIZA
Other - Middle Name:
Other - Last Name:MASAR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1820 MEMORIAL DR STE 203
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37043-4693
Mailing Address - Country:US
Mailing Address - Phone:217-649-9553
Mailing Address - Fax:
Practice Address - Street 1:1820 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37043-6326
Practice Address - Country:US
Practice Address - Phone:217-649-9553
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-25
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI80191041C0700X
TN68731041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIK400192662OtherMEDICARE
WI1619219904Medicaid
WI100043360Medicaid