Provider Demographics
NPI:1134158751
Name:COLLINGWOOD, LISA MARIE (PHD)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:COLLINGWOOD
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 1:1337 S CESAR E CHAVEZ DR
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53204-2712
Mailing Address - Country:US
Mailing Address - Phone:414-897-5511
Mailing Address - Fax:414-385-7552
Practice Address - Street 1:8204 ELMBROOK DR
Practice Address - Street 2:SUITE 360
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75247-4067
Practice Address - Country:US
Practice Address - Phone:214-219-0780
Practice Address - Fax:214-219-0782
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-03
Last Update Date:2018-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3031103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8D4562OtherBCBS
TX169676703Medicaid
TXP00246197OtherRAILROAD
TX8D4562OtherBCBS
TX169676703Medicaid