Provider Demographics
NPI:1790286698
Name:WALTRIP, LISA (LPC)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:WALTRIP
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 COMMUNITY
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MO
Mailing Address - Zip Code:64735-8804
Mailing Address - Country:US
Mailing Address - Phone:660-885-8183
Mailing Address - Fax:
Practice Address - Street 1:19515 BRUNE PKWY
Practice Address - Street 2:
Practice Address - City:WARRENTON
Practice Address - State:MO
Practice Address - Zip Code:63383-6505
Practice Address - Country:US
Practice Address - Phone:636-456-1500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-26
Last Update Date:2019-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017041096101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health