| Doctor Name: | LISA MIMMO |
| NPI Number: | 1174798862 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | PSY.D |
| License Number: | PS016292 |
| Business Practice Address: | 320 King Of Prussia Rd Radnor, PA - 190874440 |
| Business Phone Number: | 2154828000 |
| Business Fax Number: | |
| Mailing Address: | 320 King Of Prussia Rd, RADNOR |
| State: | PA |
| Postal Code: | 190874440 |
| Phone Number: | 2154828000 |
| Fax Number: | |
| NPI Enumeration Date: | 04/24/2008 |
| NPI Last Update Date: | 04/24/2008 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 101YM0800X |
| License Number: | PS016292 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | PA |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Counselor |
| Taxonomy Specialization: | Mental Health |
| Taxonomy Definition: | |