Provider Demographics
NPI:1609551738
Name:GOLLENBERG, LISA ANNE (LPC)
Entity type:Individual
Prefix:MS
First Name:LISA
Middle Name:ANNE
Last Name:GOLLENBERG
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2450 E SPEEDWAY BLVD STE 3
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85719-4748
Mailing Address - Country:US
Mailing Address - Phone:520-222-6693
Mailing Address - Fax:
Practice Address - Street 1:2450 E SPEEDWAY BLVD STE 3
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85719-4748
Practice Address - Country:US
Practice Address - Phone:520-222-6693
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-16
Last Update Date:2023-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC-22211101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional