Basic Information
| Provider Information | |||||||||
| NPI: | 1114086188 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DECATHELINEAU | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | JOY | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LMFT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 220 230TH AVE NW | ||||||||
| Address2: | |||||||||
| City: | APPLETON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 562081828 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202354613 | ||||||||
| FaxNumber: | 3202319140 | ||||||||
| Practice Location | |||||||||
| Address1: | 1234 MN-7 | ||||||||
| Address2: | |||||||||
| City: | MONTEVIDEO | ||||||||
| State: | MN | ||||||||
| PostalCode: | 56265 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202694581 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2006 | ||||||||
| LastUpdateDate: | 02/12/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/12/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 1094 | MN | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
ID Information
| ID | Type | State | Issuer | Description | 801929100 | 05 | MN | MEDICAID | 1033823 | 01 | PREFERRED ONE | OTHER | 172691 | 01 | UCARE | OTHER | 374J68T | 01 | BLUE CROSS | OTHER |