Provider Demographics
NPI:1770610388
Name:SIMON, LISA GAYE (LAC)
Entity type:Individual
Prefix:MS
First Name:LISA
Middle Name:GAYE
Last Name:SIMON
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3431 4TH AVE SW
Mailing Address - Street 2:SUITE H
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-2227
Mailing Address - Country:US
Mailing Address - Phone:701-298-8108
Mailing Address - Fax:701-297-7901
Practice Address - Street 1:3431 4TH AVE SW
Practice Address - Street 2:SUITE H
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-2227
Practice Address - Country:US
Practice Address - Phone:701-298-8108
Practice Address - Fax:701-297-7901
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1318101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor