Provider Demographics
NPI:1780925636
Name:LACOMB, LISA J (CADC I, QMHA)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:J
Last Name:LACOMB
Suffix:
Gender:F
Credentials:CADC I, QMHA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2545 N ELDORADO AVE
Mailing Address - Street 2:
Mailing Address - City:KLAMATH FALLS
Mailing Address - State:OR
Mailing Address - Zip Code:97601-6423
Mailing Address - Country:US
Mailing Address - Phone:541-883-3471
Mailing Address - Fax:541-883-3524
Practice Address - Street 1:2545 N ELDORADO AVE
Practice Address - Street 2:
Practice Address - City:KLAMATH FALLS
Practice Address - State:OR
Practice Address - Zip Code:97601-6423
Practice Address - Country:US
Practice Address - Phone:541-883-3471
Practice Address - Fax:541-883-3524
Is Sole Proprietor?:No
Enumeration Date:2013-03-01
Last Update Date:2013-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1720105489Medicaid
OR1114058898Medicaid