Provider Demographics
NPI:1649620436
Name:WILLIAMS, LISA M (CADC-I, QMHA-I)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:CADC-I, QMHA-I
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:MARIE
Other - Last Name:LONG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CADC-I: QMHA-I
Mailing Address - Street 1:300 45TH ST S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-1189
Mailing Address - Country:US
Mailing Address - Phone:480-864-5720
Mailing Address - Fax:
Practice Address - Street 1:870 82ND DR
Practice Address - Street 2:
Practice Address - City:GLADSTONE
Practice Address - State:OR
Practice Address - Zip Code:97027-1803
Practice Address - Country:US
Practice Address - Phone:503-659-5515
Practice Address - Fax:503-239-8406
Is Sole Proprietor?:No
Enumeration Date:2016-06-13
Last Update Date:2024-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 171M00000X
OR24-01-10993101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator