Provider Demographics
NPI:1679349781
Name:STREET, LISA M
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:M
Last Name:STREET
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1328 ROOT TRL
Mailing Address - Street 2:
Mailing Address - City:MARTINSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24112-5528
Mailing Address - Country:US
Mailing Address - Phone:276-358-0856
Mailing Address - Fax:
Practice Address - Street 1:1328 ROOT TRL
Practice Address - Street 2:
Practice Address - City:MARTINSVILLE
Practice Address - State:VA
Practice Address - Zip Code:24112-5528
Practice Address - Country:US
Practice Address - Phone:276-358-0856
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-29
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health