MEDICARE: MRS. LISA MARIE MANERY 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	1195	ID

General Provider Information

NPI Number	:	1235216466
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LISA MARIE MANERY LCSW

Provider Business Mailing Address
First Line	:	2273 E GALA ST STE 100
Second Line	:
City	:	MERIDIAN
State	:	ID
Zip	:	83642-7289
Country	:	US
Telephone Number	:	208-898-8999
Fax Number	:	208-898-8989

Provider Business Practice Location Address
First Line	:	2273 E GALA ST STE 100
Second Line	:
City	:	MERIDIAN
State	:	ID
Zip	:	83642-7289
Country	:	US
Telephone Number	:	208-898-8999
Fax Number	:	208-898-8989

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

Provider Enumeration Date	:	11/01/2006
Last Update Date	:	07/08/2007

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