Provider Demographics
NPI:1053528885
Name:PETROCCHI-COLLETT, LISA MARIE (MA)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:MARIE
Last Name:PETROCCHI-COLLETT
Suffix:
Gender:F
Credentials:MA
Other - Prefix:MRS
Other - First Name:LISA
Other - Middle Name:MARIE
Other - Last Name:COLLETT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA
Mailing Address - Street 1:2800 N VANCOUVER AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97227-1630
Mailing Address - Country:US
Mailing Address - Phone:503-331-2436
Mailing Address - Fax:503-331-2410
Practice Address - Street 1:2800 N VANCOUVER AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97227-1630
Practice Address - Country:US
Practice Address - Phone:503-331-2436
Practice Address - Fax:503-331-2410
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health