Provider Demographics
NPI:1659523769
Name:CORALLO, LISA MARIE (MA)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:CORALLO
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:MARIE
Other - Last Name:CORALLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:1215 SW G ST
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97526-2544
Mailing Address - Country:US
Mailing Address - Phone:541-476-2373
Mailing Address - Fax:
Practice Address - Street 1:1215 SW G ST
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97526-2544
Practice Address - Country:US
Practice Address - Phone:541-476-2373
Practice Address - Fax:541-884-2338
Is Sole Proprietor?:No
Enumeration Date:2008-10-21
Last Update Date:2019-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist