Provider Demographics
NPI:1891022919
Name:FAIRES, LISA A (MED LCPC,LMHC)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:A
Last Name:FAIRES
Suffix:
Gender:F
Credentials:MED LCPC,LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1380 PHYLLIS DR
Mailing Address - Street 2:
Mailing Address - City:MERRITT ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32952-5841
Mailing Address - Country:US
Mailing Address - Phone:207-233-1350
Mailing Address - Fax:
Practice Address - Street 1:1380 PHYLLIS DR
Practice Address - Street 2:
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32952-5841
Practice Address - Country:US
Practice Address - Phone:207-233-1350
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-10
Last Update Date:2015-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECC3775101YP2500X
FLMH 13040101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional