Provider Demographics
NPI:1174098826
Name:TREASURE, LISSA MILTON
Entity type:Individual
Prefix:
First Name:LISSA
Middle Name:MILTON
Last Name:TREASURE
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 1:187 E BUTLER LN
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97520-9380
Mailing Address - Country:US
Mailing Address - Phone:760-709-1001
Mailing Address - Fax:
Practice Address - Street 1:905 MAIN ST STE 412
Practice Address - Street 2:
Practice Address - City:KLAMATH FALLS
Practice Address - State:OR
Practice Address - Zip Code:97601-6064
Practice Address - Country:US
Practice Address - Phone:541-708-1153
Practice Address - Fax:541-273-6279
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-09
Last Update Date:2021-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
ORC6167101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500754037Medicaid