Provider Demographics
NPI:1689913667
Name:GAMMON, LISA J (MA; LPCC)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:J
Last Name:GAMMON
Suffix:
Gender:F
Credentials:MA; LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 E 4TH ST
Mailing Address - Street 2:
Mailing Address - City:CHASKA
Mailing Address - State:MN
Mailing Address - Zip Code:55318-2102
Mailing Address - Country:US
Mailing Address - Phone:952-361-1673
Mailing Address - Fax:952-361-1660
Practice Address - Street 1:600 E 4TH ST
Practice Address - Street 2:
Practice Address - City:CHASKA
Practice Address - State:MN
Practice Address - Zip Code:55318-2102
Practice Address - Country:US
Practice Address - Phone:952-361-1673
Practice Address - Fax:952-361-1660
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-11
Last Update Date:2013-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNCC00534101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional