MEDICARE: DR. LISA OWENS HENNICK PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	1466	AL

General Provider Information

NPI Number	:	1477723567
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LISA OWENS HENNICK PHD

Provider Business Mailing Address
First Line	:	2204 LAKESHORE DR STE 440
Second Line	:	440
City	:	BIRMINGHAM
State	:	AL
Zip	:	35209-6729
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2204 LAKESHORE DR STE 440
Second Line	:	440
City	:	BIRMINGHAM
State	:	AL
Zip	:	35209-6729
Country	:	US
Telephone Number	:	205-874-7844
Fax Number	:	205-874-7848

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/05/2008
Last Update Date	:	03/05/2008

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