MEDICARE: BARBARA TODAKONZIE 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	101YA0400X	Addiction (Substance Use Disorder) Counselor	LISAC-11372	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	329541-01	OTHER	AZ	1

General Provider Information

NPI Number	:	1568673051
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BARBARA TODAKONZIE LISAC

Provider Business Mailing Address
First Line	:	PO BOX 1490
Second Line	:
City	:	FORT DEFIANCE
State	:	AZ
Zip	:	86504-1490
Country	:	US
Telephone Number	:	928-729-4012
Fax Number	:	928-729-4200

Provider Business Practice Location Address
First Line	:	NAVAJO NATION RESERVATION
Second Line	:	300 YARDS SOUTH OF FORT DEFIANCE FIELDHOUSE
City	:	FORT DEFIANCE
State	:	AZ
Zip	:	86504-1490
Country	:	US
Telephone Number	:	928-729-4012
Fax Number	:	928-729-4200

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

Provider Enumeration Date	:	05/25/2007
Last Update Date	:	07/08/2007

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