MEDICARE: LISA SAFF GONZENBACH MSW

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	0969C	AL

General Provider Information

NPI Number	:	1750471041
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA SAFF GONZENBACH MSW

Provider Business Mailing Address
First Line	:	3600 WATERMELON RD
Second Line	:	SUITE 202
City	:	NORTHPORT
State	:	AL
Zip	:	35473-5169
Country	:	US
Telephone Number	:	205-750-0181
Fax Number	:	205-348-2401

Provider Business Practice Location Address
First Line	:	3600 WATERMELON RD
Second Line	:	SUITE 202
City	:	NORTHPORT
State	:	AL
Zip	:	35473-5169
Country	:	US
Telephone Number	:	205-750-0181
Fax Number	:	205-348-2401

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

Provider Enumeration Date	:	10/15/2006
Last Update Date	:	07/09/2007

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