MEDICARE: DR. LISA BETHANY MAGAZINE PHD

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	103TC0700X	Clinical Psychologist	0810003813	VA

General Provider Information

NPI Number	:	1154503217
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LISA BETHANY MAGAZINE PHD

Provider Business Mailing Address
First Line	:	6610 COMMONS DR
Second Line	:	STE #103
City	:	PRINCE GEORGE
State	:	VA
Zip	:	23875-2528
Country	:	US
Telephone Number	:	804-722-0620
Fax Number	:	804-722-0621

Provider Business Practice Location Address
First Line	:	6610 COMMONS DR
Second Line	:	STE #103
City	:	PRINCE GEORGE
State	:	VA
Zip	:	23875-2528
Country	:	US
Telephone Number	:	804-722-0620
Fax Number	:	804-722-0621

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

Provider Enumeration Date	:	11/30/2007
Last Update Date	:	11/30/2007

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