Provider Demographics
NPI:1851043863
Name:THEOFELIS, LISA EMILY (MC61250418)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:EMILY
Last Name:THEOFELIS
Suffix:
Gender:F
Credentials:MC61250418
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1322 S 235TH PL
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:WA
Mailing Address - Zip Code:98198-5426
Mailing Address - Country:US
Mailing Address - Phone:206-914-4697
Mailing Address - Fax:
Practice Address - Street 1:1322 S 235TH PL
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:WA
Practice Address - Zip Code:98198-5426
Practice Address - Country:US
Practice Address - Phone:206-914-4697
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-20
Last Update Date:2022-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMC.61250418101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health