MEDICARE: LISA MUCKER 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	13282	LA

General Provider Information

NPI Number	:	1295382349
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA MUCKER LCSW

Provider Business Mailing Address
First Line	:	23136 ARCWOOD DR
Second Line	:
City	:	DENHAM SPRINGS
State	:	LA
Zip	:	70726-2323
Country	:	US
Telephone Number	:	225-241-9954
Fax Number	:

Provider Business Practice Location Address
First Line	:	1234 DEL ESTE AVE STE 901
Second Line	:
City	:	DENHAM SPRINGS
State	:	LA
Zip	:	70726-4828
Country	:	US
Telephone Number	:	225-360-5372
Fax Number	:

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

Provider Enumeration Date	:	08/23/2019
Last Update Date	:	10/08/2019

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