MEDICARE: RAYMOND C LISAUCKIS 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	S03283	TX
2	104100000X	Social Worker	03283	TX
3	101YM0800X	Mental Health Counselor	03283	TX
4	101Y00000X	Counselor	03283	TX
5	171M00000X	Case Manager/Care Coordinator	03283	TX

General Provider Information

NPI Number	:	1255331013
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RAYMOND C LISAUCKIS LCSW

Provider Business Mailing Address
First Line	:	800 EVERGREEN LN
Second Line	:
City	:	BURLESON
State	:	TX
Zip	:	76028-8410
Country	:	US
Telephone Number	:	817-295-3736
Fax Number	:

Provider Business Practice Location Address
First Line	:	4800 MEMORIAL DR
Second Line	:	VA MEDICAL CENTER (124-VIST-W)
City	:	WACO
State	:	TX
Zip	:	76711-1329
Country	:	US
Telephone Number	:	254-297-3123
Fax Number	:	243-297-5387

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

Provider Enumeration Date	:	07/22/2005
Last Update Date	:	10/21/2008

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