1114086188 NPI number — MRS. LISA JOY DECATHELINEAU LMFT

Table of content: MRS. LISA JOY DECATHELINEAU LMFT (NPI 1114086188)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114086188 NPI number — MRS. LISA JOY DECATHELINEAU LMFT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DECATHELINEAU
Provider First Name:
LISA
Provider Middle Name:
JOY
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LMFT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114086188
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/12/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
220 230TH AVE NW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
APPLETON
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56208-1828
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
320-235-4613
Provider Business Mailing Address Fax Number:
320-231-9140

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1234 MN-7
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MONTEVIDEO
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56265
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
320-269-4581
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/06/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 106H00000X , with the licence number:  1094 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 801929100 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1033823 . This is a "PREFERRED ONE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 172691 . This is a "UCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 374J68T . This is a "BLUE CROSS" identifier . This identifiers is of the category "OTHER".