Provider Demographics
NPI:1174561740
Name:POULOS, LISA M
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:POULOS
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 1:603 DOLLEY MADISON RD STE 100
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27410-4282
Mailing Address - Country:US
Mailing Address - Phone:336-632-3505
Mailing Address - Fax:336-665-6188
Practice Address - Street 1:603 DOLLEY MADISON RD STE 100
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27410-4282
Practice Address - Country:US
Practice Address - Phone:336-632-3505
Practice Address - Fax:336-665-6188
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2019-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC950023163WP0808X, 364SP0807X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
No364SP0807XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Child & Adolescent