Provider Demographics
NPI:1881177012
Name:LOWERY, LISA YAVETTE (CACDI 02137-L)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:YAVETTE
Last Name:LOWERY
Suffix:
Gender:F
Credentials:CACDI 02137-L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3583 SPRING SHOWER DR
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89147-3733
Mailing Address - Country:US
Mailing Address - Phone:206-245-0775
Mailing Address - Fax:
Practice Address - Street 1:3920 W CHARLESTON BLVD STE O
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102-1633
Practice Address - Country:US
Practice Address - Phone:702-478-5541
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-13
Last Update Date:2018-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV02137-L101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV02137-LMedicaid