Provider Demographics
NPI:1013738749
Name:FIRESTINE, LISA MICHELLE (LMHC)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:MICHELLE
Last Name:FIRESTINE
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3715 INDIANA AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46807-2213
Mailing Address - Country:US
Mailing Address - Phone:260-849-2041
Mailing Address - Fax:
Practice Address - Street 1:6157 STONEY CREEK DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-4409
Practice Address - Country:US
Practice Address - Phone:260-570-4515
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-24
Last Update Date:2024-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39002689A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health