Provider Demographics
NPI:1942474887
Name:BOTTOMLEY, LISA MADELLE (LMHC)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MADELLE
Last Name:BOTTOMLEY
Suffix:
Gender:F
Credentials:LMHC
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 127
Mailing Address - Street 2:
Mailing Address - City:CHIMACUM
Mailing Address - State:WA
Mailing Address - Zip Code:98325-0127
Mailing Address - Country:US
Mailing Address - Phone:360-774-0790
Mailing Address - Fax:360-379-8821
Practice Address - Street 1:219C WEST PATISON
Practice Address - Street 2:
Practice Address - City:PORT HADLOCK
Practice Address - State:WA
Practice Address - Zip Code:98339
Practice Address - Country:US
Practice Address - Phone:360-774-0790
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-22
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH00011150101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health