Provider Demographics
NPI:1972856060
Name:LISOWE, LIDA (NCC, LPCA)
Entity Type:Individual
Prefix:
First Name:LIDA
Middle Name:
Last Name:LISOWE
Suffix:
Gender:F
Credentials:NCC, LPCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8604 ERINSBROOK DR
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27617-8338
Mailing Address - Country:US
Mailing Address - Phone:919-322-9699
Mailing Address - Fax:
Practice Address - Street 1:3725 NATIONAL DR
Practice Address - Street 2:SUITE 220
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27612-4066
Practice Address - Country:US
Practice Address - Phone:919-781-8370
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-26
Last Update Date:2016-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC8452101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health