Healthcare Provider Details

I. General information

NPI: 1619968500
Provider Name (Legal Business Name): LISA A FOODIM L.C.S.W.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2005
Last Update Date: 10/20/2021
Certification Date: 10/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 DEANNE AVE
NEWCASTLE WY
82701-2936
US

IV. Provider business mailing address

909 LONG DR STE C
SHERIDAN WY
82801-3282
US

V. Phone/Fax

Practice location:
  • Phone: 307-746-4456
  • Fax:
Mailing address:
  • Phone: 307-672-8958
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-1357
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: