Healthcare Provider Details

I. General information

NPI: 1881567840
Provider Name (Legal Business Name): ILLISA LEA LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2025
Last Update Date: 09/10/2026
Certification Date: 09/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 LEBANON RD
MURFREESBORO TN
37129-1392
US

IV. Provider business mailing address

588 NEAL RD
WATERTOWN TN
37184-3609
US

V. Phone/Fax

Practice location:
  • Phone: 615-946-6985
  • Fax:
Mailing address:
  • Phone: 615-946-6985
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number13852
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: