Healthcare Provider Details

I. General information

NPI: 1346561297
Provider Name (Legal Business Name): LISA M MAHER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2010
Last Update Date: 06/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 W MAIN ST
CASA GRANDE AZ
85122-4820
US

IV. Provider business mailing address

210 E COTTONWOOD LN
CASA GRANDE AZ
85122-2514
US

V. Phone/Fax

Practice location:
  • Phone: 520-836-1675
  • Fax: 520-421-1969
Mailing address:
  • Phone: 520-836-1688
  • Fax: 520-421-2708

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLISAC-10385
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: