Provider Demographics
NPI:1134974207
Name:HARDAWAY, LISA
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:HARDAWAY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:432057 STATE HIGHWAY 3
Mailing Address - Street 2:
Mailing Address - City:FORT TOWSON
Mailing Address - State:OK
Mailing Address - Zip Code:74735-7506
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:580-209-6179
Practice Address - Street 1:17 S CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:IDABEL
Practice Address - State:OK
Practice Address - Zip Code:74745-4625
Practice Address - Country:US
Practice Address - Phone:580-353-9726
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-22
Last Update Date:2024-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician