Healthcare Provider Details

I. General information

NPI: 1396973988
Provider Name (Legal Business Name): LISA D TAYLOR PHD, TLP, LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/23/2009
Last Update Date: 10/14/2025
Certification Date: 10/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

652 PO BOX
AVONDALE ESTATES GA
30002
US

IV. Provider business mailing address

PO BOX 652
AVONDALE ESTATES GA
30002-0652
US

V. Phone/Fax

Practice location:
  • Phone: 678-517-9984
  • Fax:
Mailing address:
  • Phone: 678-517-9984
  • Fax: 404-292-9424

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6362009715
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW003493
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801084326
License Number StateMI
# 4
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number400719
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: