MEDICARE: MRS. LISA SA'RENA FRIEND

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	251S00000X	Community/Behavioral Health Agency	7542	VA

General Provider Information

NPI Number	:	1215711692
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LISA SA'RENA FRIEND

Provider Business Mailing Address
First Line	:	510 S SYCAMORE ST STE 3
Second Line	:
City	:	PETERSBURG
State	:	VA
Zip	:	23803-5044
Country	:	US
Telephone Number	:	804-894-8829
Fax Number	:	804-535-5955

Provider Business Practice Location Address
First Line	:	510 S SYCAMORE ST STE 3
Second Line	:
City	:	PETERSBURG
State	:	VA
Zip	:	23803-5044
Country	:	US
Telephone Number	:	804-894-8829
Fax Number	:	804-535-5955

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

Provider Enumeration Date	:	08/24/2023
Last Update Date	:	09/11/2023

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