Provider Demographics
NPI:1679724363
Name:LAUDERDALE, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:LAUDERDALE
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 1:20404 E 410 ROAD
Mailing Address - Street 2:
Mailing Address - City:CHELSEA
Mailing Address - State:OK
Mailing Address - Zip Code:74016
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:24797 S HWY 66
Practice Address - Street 2:SUITE 5
Practice Address - City:CLAREMORE
Practice Address - State:OK
Practice Address - Zip Code:74019-2411
Practice Address - Country:US
Practice Address - Phone:918-342-2080
Practice Address - Fax:918-342-0075
Is Sole Proprietor?:No
Enumeration Date:2008-10-01
Last Update Date:2012-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health