Provider Demographics
NPI:1932698248
Name:WANEK, LISA (LMFT)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:WANEK
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 SUMMIT TER APT 45
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-2210
Mailing Address - Country:US
Mailing Address - Phone:203-362-7777
Mailing Address - Fax:
Practice Address - Street 1:71 US ROUTE 1
Practice Address - Street 2:
Practice Address - City:SCARBOROUGH
Practice Address - State:ME
Practice Address - Zip Code:04074-7173
Practice Address - Country:US
Practice Address - Phone:207-772-1187
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-02
Last Update Date:2020-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMF5709106H00000X
METXM5023106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist