Provider Demographics
NPI:1053697979
Name:MATZKE, LISA J (LPC)
Entity type:Individual
Prefix:MS
First Name:LISA
Middle Name:J
Last Name:MATZKE
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1445 LOOKOUT DR STE 200
Mailing Address - Street 2:
Mailing Address - City:NORTH MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56003-2501
Mailing Address - Country:US
Mailing Address - Phone:507-340-5126
Mailing Address - Fax:507-345-8861
Practice Address - Street 1:1445 LOOKOUT DR STE 200
Practice Address - Street 2:
Practice Address - City:NORTH MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56003-2501
Practice Address - Country:US
Practice Address - Phone:507-340-5126
Practice Address - Fax:507-345-8861
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-24
Last Update Date:2011-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN01108101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional