Healthcare Provider Details

I. General information

NPI: 1265544670
Provider Name (Legal Business Name): LISA T SANFORD LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 07/05/2025
Certification Date: 07/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1864 BUTTERNUT DR
GROVETOWN GA
30813-0591
US

IV. Provider business mailing address

1864 BUTTERNUT DR
GROVETOWN GA
30813-0591
US

V. Phone/Fax

Practice location:
  • Phone: 706-339-5209
  • Fax:
Mailing address:
  • Phone: 706-339-5209
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW004490
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: