=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427723220
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LISA RENEE GEORGE LMSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/12/2021
-----------------------------------------------------
Last Update Date | 08/12/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 675 E BIG BEAVER RD STE 207
-----------------------------------------------------
City | TROY
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48083-1428
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-677-1421
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 23543 PLAYVIEW ST
-----------------------------------------------------
City | SAINT CLAIR SHORES
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48082-2093
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-707-3630
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
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 | 6801065950
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------