Provider Demographics
NPI:1689491946
Name:FEITZ, LISA ANN
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:ANN
Last Name:FEITZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12645 TYLER RD
Mailing Address - Street 2:
Mailing Address - City:LAKEVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46536-9612
Mailing Address - Country:US
Mailing Address - Phone:574-784-2311
Mailing Address - Fax:
Practice Address - Street 1:12645 TYLER RD
Practice Address - Street 2:
Practice Address - City:LAKEVILLE
Practice Address - State:IN
Practice Address - Zip Code:46536-9612
Practice Address - Country:US
Practice Address - Phone:574-784-2311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-26
Last Update Date:2024-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10135618103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool