MEDICARE: MS. LISA BENNER LCSW, LISAC

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	1041C0700X	Clinical Social Worker	LW00009518	WA

General Provider Information

NPI Number	:	1508143702
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. LISA BENNER LCSW, LISAC

Provider Business Mailing Address
First Line	:	PO BOX 746878
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30374-6878
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	PO BOX 746878
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30374-6878
Country	:	US
Telephone Number	:	866-277-9071
Fax Number	:

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

Provider Enumeration Date	:	11/16/2011
Last Update Date	:	11/05/2025

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