Provider Demographics
NPI:1679051429
Name:EARLY, LISA A (LGPC)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:A
Last Name:EARLY
Suffix:
Gender:F
Credentials:LGPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:742 VILLAGER CIR
Mailing Address - Street 2:
Mailing Address - City:DUNDALK
Mailing Address - State:MD
Mailing Address - Zip Code:21222-8802
Mailing Address - Country:US
Mailing Address - Phone:240-888-0614
Mailing Address - Fax:
Practice Address - Street 1:900 S MAIN ST BLDG A
Practice Address - Street 2:
Practice Address - City:BEL AIR
Practice Address - State:MD
Practice Address - Zip Code:21014-5447
Practice Address - Country:US
Practice Address - Phone:410-914-4012
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-03
Last Update Date:2023-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC10301101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health