Provider Demographics
NPI:1659514503
Name:VAN TASSELL, LISA (MA, LPC)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:VAN TASSELL
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 SILVER LAKE RD NW
Mailing Address - Street 2:SUITE 110
Mailing Address - City:NEW BRIGHTON
Mailing Address - State:MN
Mailing Address - Zip Code:55112-1786
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9075 QUADAY AVE NE
Practice Address - Street 2:SUITE 102
Practice Address - City:ELK RIVER
Practice Address - State:MN
Practice Address - Zip Code:55330-6672
Practice Address - Country:US
Practice Address - Phone:763-746-9492
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-08
Last Update Date:2009-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLPC00537101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional