=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205964236
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LISA SUSAN LIPORACE L.C.S.W.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/01/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 580 VILLAGE BLVD SUITE 210
-----------------------------------------------------
City | WEST PALM BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33409-1904
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-688-5050
-----------------------------------------------------
Fax | 561-688-9565
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 402 VIA PLACITA
-----------------------------------------------------
City | PALM BEACH GARDENS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33418-1727
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-630-5213
-----------------------------------------------------
Fax | 561-656-2735
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | SW3729
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------