Provider Demographics
NPI:1710280698
Name:JOHN, LISA
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:
Last Name:JOHN
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 1:16017 COUNTY ROAD 3535
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74820-0850
Mailing Address - Country:US
Mailing Address - Phone:580-272-3217
Mailing Address - Fax:
Practice Address - Street 1:124 S BROADWAY AVE STE 200
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820-5825
Practice Address - Country:US
Practice Address - Phone:580-332-3001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-14
Last Update Date:2014-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor