Healthcare Provider Details

I. General information

NPI: 1598278038
Provider Name (Legal Business Name): LISA A AUDINO LCSW, CADC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LISA A ROBERTS

II. Dates (important events)

Enumeration Date: 11/07/2017
Last Update Date: 08/30/2020
Certification Date: 08/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

467 HADLEY MILL RD
JACKSON ME
04921-3119
US

IV. Provider business mailing address

PO BOX 115
BROOKS ME
04921-0115
US

V. Phone/Fax

Practice location:
  • Phone: 207-505-6082
  • Fax: 330-266-7303
Mailing address:
  • Phone: 207-505-6082
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLC18634
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: