Provider Demographics
NPI:1851287742
Name:FETICK, LISA HACKETT
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:HACKETT
Last Name:FETICK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:MARIE
Other - Last Name:HACKETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1323 SW OKLAHOMA AVE SIDE A
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73501-8021
Mailing Address - Country:US
Mailing Address - Phone:513-237-3421
Mailing Address - Fax:
Practice Address - Street 1:1323 SW OKLAHOMA AVE SIDE A
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73501-8021
Practice Address - Country:US
Practice Address - Phone:513-237-3421
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-16
Last Update Date:2025-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchoolGroup - Single Specialty