Healthcare Provider Details

I. General information

NPI: 1588796668
Provider Name (Legal Business Name): LISA A.M. INNES CSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/12/2007
Last Update Date: 03/16/2022
Certification Date: 03/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

845 ANGLIANA AVE
LEXINGTON KY
40508-3146
US

IV. Provider business mailing address

1351 NEWTOWN PIKE
LEXINGTON KY
40511-1217
US

V. Phone/Fax

Practice location:
  • Phone: 859-323-9321
  • Fax: 859-257-5232
Mailing address:
  • Phone: 859-253-1686
  • Fax: 859-254-2743

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number3569
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number256308
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: