Provider Demographics
NPI:1144919036
Name:BAZEMORE, LISA MICHELLE (LCAS-A)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:MICHELLE
Last Name:BAZEMORE
Suffix:
Gender:F
Credentials:LCAS-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:351 US 13-17 SOUTH
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:NC
Mailing Address - Zip Code:27983
Mailing Address - Country:US
Mailing Address - Phone:252-794-4393
Mailing Address - Fax:
Practice Address - Street 1:216 STEWART PKWY
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:NC
Practice Address - Zip Code:27889-4972
Practice Address - Country:US
Practice Address - Phone:252-946-0585
Practice Address - Fax:252-946-0580
Is Sole Proprietor?:No
Enumeration Date:2023-05-05
Last Update Date:2023-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLCAS-20667101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)