MEDICARE: LISA J TERRY MSW, LCSW

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	4258	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	Z7258	OTHER	FL	BCBS PROVIDER NUMBER

General Provider Information

NPI Number	:	1154345452
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA J TERRY MSW, LCSW

Provider Business Mailing Address
First Line	:	847 20TH PL
Second Line	:
City	:	VERO BEACH
State	:	FL
Zip	:	32960-5357
Country	:	US
Telephone Number	:	772-633-6723
Fax Number	:

Provider Business Practice Location Address
First Line	:	3150 CARDINAL DR STE 201
Second Line	:
City	:	VERO BEACH
State	:	FL
Zip	:	32963-1931
Country	:	US
Telephone Number	:	772-633-6723
Fax Number	:

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

Provider Enumeration Date	:	07/27/2006
Last Update Date	:	07/23/2024

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