Provider Demographics
NPI:1053781336
Name:WING, LISA M (LCPC-C)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:WING
Suffix:
Gender:F
Credentials:LCPC-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 EAGLE DR
Mailing Address - Street 2:
Mailing Address - City:NORTHPORT
Mailing Address - State:ME
Mailing Address - Zip Code:04849-3253
Mailing Address - Country:US
Mailing Address - Phone:207-631-7626
Mailing Address - Fax:
Practice Address - Street 1:12 EAGLE DR
Practice Address - Street 2:
Practice Address - City:NORTHPORT
Practice Address - State:ME
Practice Address - Zip Code:04849-3253
Practice Address - Country:US
Practice Address - Phone:207-631-7626
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-30
Last Update Date:2024-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEXL4577101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional