Provider Demographics
NPI:1851725626
Name:COURCHAINE, LISA BETH (LCSW)
Entity Type:Individual
Prefix:MISS
First Name:LISA
Middle Name:BETH
Last Name:COURCHAINE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1515 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:WI
Mailing Address - Zip Code:53925-2402
Mailing Address - Country:US
Mailing Address - Phone:920-623-2200
Mailing Address - Fax:
Practice Address - Street 1:1515 PARK AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:WI
Practice Address - Zip Code:53925-2402
Practice Address - Country:US
Practice Address - Phone:920-623-2200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-28
Last Update Date:2023-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8428-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100032648Medicaid
WI8428-123OtherLICENSE