MEDICARE: MRS. LISA MUNDAY LCSWA

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	1041C0700X	Clinical Social Worker	P013239	NC

General Provider Information

NPI Number	:	1073071494
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LISA MUNDAY LCSWA

Provider Business Mailing Address
First Line	:	11110 LORWIND CT
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28262-4439
Country	:	US
Telephone Number	:	704-996-0119
Fax Number	:

Provider Business Practice Location Address
First Line	:	4724 PARK RD STE D
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28209-4204
Country	:	US
Telephone Number	:	704-996-0119
Fax Number	:

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

Provider Enumeration Date	:	03/05/2019
Last Update Date	:	03/05/2019

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