Provider Demographics
NPI:1922048859
Name:PATTISON, LISA A (PHD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:A
Last Name:PATTISON
Suffix:
Gender:F
Credentials:PHD
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 5194
Mailing Address - Street 2:3280 WOODRIDGE BLVD SUITE 200
Mailing Address - City:GRAND ISLAND
Mailing Address - State:NE
Mailing Address - Zip Code:68802-5194
Mailing Address - Country:US
Mailing Address - Phone:308-382-1764
Mailing Address - Fax:308-395-3730
Practice Address - Street 1:3280 WOODRIDGE BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:GRAND ISLAND
Practice Address - State:NE
Practice Address - Zip Code:68801-5194
Practice Address - Country:US
Practice Address - Phone:308-382-1764
Practice Address - Fax:308-395-3730
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-08
Last Update Date:2014-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE325103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47078358200Medicaid
NE47078358200Medicaid
NE098477Medicare PIN