Provider Demographics
NPI:1871247734
Name:SANTOS, LISA (LAC)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:SANTOS
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16620 N 40TH ST STE G1
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85032-3351
Mailing Address - Country:US
Mailing Address - Phone:602-363-0629
Mailing Address - Fax:480-247-4179
Practice Address - Street 1:7155 W CAMPO BELLO DR STE C120
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-8590
Practice Address - Country:US
Practice Address - Phone:602-363-0629
Practice Address - Fax:480-247-4179
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-09
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC16402101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional