MEDICARE: DANIEL BLEW LISAC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101Y00000X	Counselor	15079	AZ
2	101YA0400X	Addiction (Substance Use Disorder) Counselor	15079	AZ

General Provider Information

NPI Number	:	1043728082
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DANIEL BLEW LISAC

Provider Business Mailing Address
First Line	:	1076 W CHANDLER BLVD STE 113
Second Line	:
City	:	CHANDLER
State	:	AZ
Zip	:	85224-5205
Country	:	US
Telephone Number	:	480-809-6010
Fax Number	:

Provider Business Practice Location Address
First Line	:	1076 W CHANDLER BLVD STE 113
Second Line	:
City	:	CHANDLER
State	:	AZ
Zip	:	85224-5205
Country	:	US
Telephone Number	:	480-809-6230
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/11/2018
Last Update Date	:	11/09/2022

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Directions to “ DANIEL BLEW LISAC” Practice Location

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