Healthcare Provider Details

I. General information

NPI: 1194186866
Provider Name (Legal Business Name): LISA GOTTFRIED
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/09/2016
Last Update Date: 03/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

49 BOONE VILLAGE SUITE #322
ZIONSVILLE IN
46077
US

IV. Provider business mailing address

49 BOONE VILLAGE SUITE #322
ZIONSVILLE IN
46077
US

V. Phone/Fax

Practice location:
  • Phone: 219-895-6103
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: