Healthcare Provider Details

I. General information

NPI: 1356093702
Provider Name (Legal Business Name): CHRISTINE ELAINE LISS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/26/2022
Last Update Date: 03/08/2023
Certification Date: 03/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11111 HOUZE RD STE 225
ROSWELL GA
30076-5618
US

IV. Provider business mailing address

4184 NASHOBA DR NE
ROSWELL GA
30075-1667
US

V. Phone/Fax

Practice location:
  • Phone: 770-603-0123
  • Fax: 770-910-9919
Mailing address:
  • Phone: 404-786-0882
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberMSW007511
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW008482
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: