Provider Demographics
NPI:1861835829
Name:REYNOSO, LISA MORTIE (MA, LPCC)
Entity Type:Individual
Prefix:MISS
First Name:LISA
Middle Name:MORTIE
Last Name:REYNOSO
Suffix:
Gender:F
Credentials:MA, LPCC
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:MORTIE
Other - Last Name:RAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, LPCC
Mailing Address - Street 1:12497 DRAKE ST NW
Mailing Address - Street 2:
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55448-2095
Mailing Address - Country:US
Mailing Address - Phone:763-464-7219
Mailing Address - Fax:
Practice Address - Street 1:630 E MAIN ST
Practice Address - Street 2:
Practice Address - City:ANOKA
Practice Address - State:MN
Practice Address - Zip Code:55303-2527
Practice Address - Country:US
Practice Address - Phone:763-712-1903
Practice Address - Fax:763-712-1917
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-09
Last Update Date:2014-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN573101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health