Basic Information
| Provider Information | |||||||||
| NPI: | 1790083491 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LOZANO | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | M. | ||||||||
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| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3883 | ||||||||
| Address2: | |||||||||
| City: | GILLETTE | ||||||||
| State: | WY | ||||||||
| PostalCode: | 827173883 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3076826699 | ||||||||
| FaxNumber: | 3076877243 | ||||||||
| Practice Location | |||||||||
| Address1: | 1401 W 2ND ST | ||||||||
| Address2: | SUITE #1 | ||||||||
| City: | GILLETTE | ||||||||
| State: | WY | ||||||||
| PostalCode: | 827163333 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3076826699 | ||||||||
| FaxNumber: | 3076877243 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/03/2011 | ||||||||
| LastUpdateDate: | 03/03/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | PPC-458 | WY | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | PPC-458 | 01 | WY | STATE LICENSE NUMBER | OTHER |