Provider Demographics
NPI:1881322873
Name:JOHNSON, LISA INEZ (MSC, LAC)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:INEZ
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MSC, LAC
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:INEZ
Other - Last Name:CASTILLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSC, LAC
Mailing Address - Street 1:4032 W QUESTA DR
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85310-3255
Mailing Address - Country:US
Mailing Address - Phone:602-741-1812
Mailing Address - Fax:
Practice Address - Street 1:7730 E GREENWAY RD STE 205
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85260-1788
Practice Address - Country:US
Practice Address - Phone:480-774-3040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-09
Last Update Date:2022-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC-20298101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health