Provider Demographics
NPI:1922402882
Name:BRUBAKER, LISA (LCSW)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:BRUBAKER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:BRUBAKER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:PO BOX 602
Mailing Address - Street 2:
Mailing Address - City:ENNIS
Mailing Address - State:MT
Mailing Address - Zip Code:59729-0602
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5 SUNRISE LOOP STE G
Practice Address - Street 2:
Practice Address - City:ENNIS
Practice Address - State:MT
Practice Address - Zip Code:59729-8009
Practice Address - Country:US
Practice Address - Phone:406-670-4546
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-21
Last Update Date:2020-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT81501041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT7193589Medicaid