Provider Demographics
NPI:1245852946
Name:FRACICA, LISA (MA, LCPC, LGPAT)
Entity type:Individual
Prefix:MS
First Name:LISA
Middle Name:
Last Name:FRACICA
Suffix:
Gender:F
Credentials:MA, LCPC, LGPAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:803 S ROSE ST
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21224-3740
Mailing Address - Country:US
Mailing Address - Phone:816-752-6631
Mailing Address - Fax:
Practice Address - Street 1:2511 STADIUM DR
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406-6606
Practice Address - Country:US
Practice Address - Phone:816-752-6631
Practice Address - Fax:844-919-1630
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-15
Last Update Date:2023-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDATG239221700000X
MDLC12493101YP2500X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist