Provider Demographics
NPI:1841529930
Name:LISA S. SQUIRE, PHD, LP, PA
Entity type:Organization
Organization Name:LISA S. SQUIRE, PHD, LP, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LISA
Authorized Official - Middle Name:SHARON
Authorized Official - Last Name:SQUIRE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD PSYCHOLOGY
Authorized Official - Phone:952-854-2440
Mailing Address - Street 1:7800 METRO PKWY
Mailing Address - Street 2:SUITE 300
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55425-1514
Mailing Address - Country:US
Mailing Address - Phone:952-854-2440
Mailing Address - Fax:952-854-2465
Practice Address - Street 1:7800 METRO PKWY
Practice Address - Street 2:SUITE 300
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55425-1514
Practice Address - Country:US
Practice Address - Phone:952-854-2440
Practice Address - Fax:952-854-2465
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-18
Last Update Date:2009-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNMNLP0204103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN680001602Medicare PIN