Provider Demographics
NPI:1912348764
Name:MINOR, LISA RIVKA LIBSTER (PHD, HSPP, BCBA-D)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:RIVKA LIBSTER
Last Name:MINOR
Suffix:
Gender:F
Credentials:PHD, HSPP, BCBA-D
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:RIVKA
Other - Last Name:LIBSTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:614 E 52ND ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46205-1156
Mailing Address - Country:US
Mailing Address - Phone:410-440-5381
Mailing Address - Fax:
Practice Address - Street 1:1061 E SOUTHERN AVENUE
Practice Address - Street 2:DIAGNOSTIC OFFICE
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46203
Practice Address - Country:US
Practice Address - Phone:317-207-1986
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-09
Last Update Date:2022-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
11212660103K00000X
IN20042808A103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst