Provider Demographics
NPI:1902038441
Name:ECKERT, LISA (MS)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:ECKERT
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3160
Mailing Address - Street 2:
Mailing Address - City:APACHE JUNCTION
Mailing Address - State:AZ
Mailing Address - Zip Code:85117-3160
Mailing Address - Country:US
Mailing Address - Phone:480-474-5618
Mailing Address - Fax:480-288-5339
Practice Address - Street 1:564 N IDAHO RD
Practice Address - Street 2:
Practice Address - City:APACHE JUNCTION
Practice Address - State:AZ
Practice Address - Zip Code:85219-4002
Practice Address - Country:US
Practice Address - Phone:480-893-0065
Practice Address - Fax:480-983-3676
Is Sole Proprietor?:No
Enumeration Date:2009-08-18
Last Update Date:2009-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ10297106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZPENDINGMedicaid