MEDICARE: MS. LISA LYNN WHITE MSW 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	103T00000X	Psychologist	989114	CO
2	1041C0700X	Clinical Social Worker

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1376684597
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. LISA LYNN WHITE MSW LCSW

Provider Business Mailing Address
First Line	:	1751 S 8TH ST
Second Line	:
City	:	CO SPGS
State	:	CO
Zip	:	80906
Country	:	US
Telephone Number	:	719-471-1816
Fax Number	:	719-471-9987

Provider Business Practice Location Address
First Line	:	1751 S 8TH ST
Second Line	:
City	:	CO SPGS
State	:	CO
Zip	:	80906
Country	:	US
Telephone Number	:	719-471-1816
Fax Number	:	719-471-9987

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

Provider Enumeration Date	:	02/09/2007
Last Update Date	:	06/08/2021

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