MEDICARE: LISA IRWIN, LLC

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	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1366205957
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LISA IRWIN, LLC

Provider Business Mailing Address
First Line	:	112 N JACKSON ST
Second Line	:
City	:	ENID
State	:	OK
Zip	:	73701-3848
Country	:	US
Telephone Number	:	580-254-1535
Fax Number	:	580-237-1947

Provider Business Practice Location Address
First Line	:	112 N JACKSON ST
Second Line	:
City	:	ENID
State	:	OK
Zip	:	73701-3848
Country	:	US
Telephone Number	:	580-254-1535
Fax Number	:	580-237-1947

Authorized Official
Title or Position	:	OWNER/COUNSELOR
Name	:	MRS. LISA IRWIN
Credential	:	LPC
Telephone Number	:	580-254-1535

Provider Enumeration Date	:	02/05/2024
Last Update Date	:	02/05/2024

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