Provider Demographics
NPI:1669881348
Name:CRISWELL, LISA KRISTINE (PSYD)
Entity type:Individual
Prefix:MS
First Name:LISA
Middle Name:KRISTINE
Last Name:CRISWELL
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:MS
Other - First Name:LISA
Other - Middle Name:KRISTINE
Other - Last Name:TANKERSLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1505 16TH LANE NE
Mailing Address - Street 2:UNIT 404
Mailing Address - City:ISSAQUAH
Mailing Address - State:WA
Mailing Address - Zip Code:98029
Mailing Address - Country:US
Mailing Address - Phone:209-456-6975
Mailing Address - Fax:785-452-4932
Practice Address - Street 1:75 NW DOGWOOD STREET
Practice Address - Street 2:SUITE B
Practice Address - City:ISSAQUAH
Practice Address - State:WA
Practice Address - Zip Code:98027
Practice Address - Country:US
Practice Address - Phone:425-269-3277
Practice Address - Fax:785-452-4932
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-07
Last Update Date:2018-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY60628904103T00000X
KS2538103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist