Basic Information
| Provider Information | |||||||||
| NPI: | 1457501173 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROEHL | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | A. | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MA, CPC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SAA | ||||||||
| OtherFirstName: | LISA | ||||||||
| OtherMiddleName: | A. | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1155 N MAYFAIR RD | ||||||||
| Address2: | DEPARTMENT OF PSYCHIATRY | ||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532263462 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4149558900 | ||||||||
| FaxNumber: | 4149556285 | ||||||||
| Practice Location | |||||||||
| Address1: | 1155 N MAYFAIR RD | ||||||||
| Address2: | DEPARTMENT OF PSYCHIATRY | ||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532263462 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4149558900 | ||||||||
| FaxNumber: | 4149556285 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/30/2008 | ||||||||
| LastUpdateDate: | 11/02/2012 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 2946 | WI | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 1457501173 | 05 | WI | MEDICAID | 43568500 | 05 | WI | MEDICAID |