Provider Demographics
NPI:1790645406
Name:VANDERHEIDEN, LISA
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:VANDERHEIDEN
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 1:531 W 7TH ST
Mailing Address - Street 2:
Mailing Address - City:PORT ANGELES
Mailing Address - State:WA
Mailing Address - Zip Code:98362-5807
Mailing Address - Country:US
Mailing Address - Phone:360-690-9159
Mailing Address - Fax:
Practice Address - Street 1:435 W BELL ST STE B
Practice Address - Street 2:
Practice Address - City:SEQUIM
Practice Address - State:WA
Practice Address - Zip Code:98382-2916
Practice Address - Country:US
Practice Address - Phone:360-690-9159
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-11-14
Last Update Date:2025-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMHCA.MC.70026951101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health