Healthcare Provider Details

I. General information

NPI: 1023038502
Provider Name (Legal Business Name): LISA W GENECOV MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7777 FOREST LN SUITE B 326
DALLAS TX
75230-2505
US

IV. Provider business mailing address

7777 FOREST LN SUITE B 326
DALLAS TX
75230-2505
US

V. Phone/Fax

Practice location:
  • Phone: 972-566-8466
  • Fax: 972-566-8329
Mailing address:
  • Phone: 972-566-8466
  • Fax: 972-566-8329

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0006X
TaxonomyDevelopmental - Behavioral Pediatrics Physician
License NumberH8068
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: