MEDICARE: OLIVIA R TISA LGSW

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	104100000X	Social Worker	LG200002837	DC

General Provider Information

NPI Number	:	1649138553
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	OLIVIA R TISA LGSW

Provider Business Mailing Address
First Line	:	2425 17TH ST NW APT 21
Second Line	:
City	:	WASHINGTON
State	:	DC
Zip	:	20009-2798
Country	:	US
Telephone Number	:	708-846-0478
Fax Number	:

Provider Business Practice Location Address
First Line	:	4400 MACARTHUR BLVD NW STE 300
Second Line	:
City	:	WASHINGTON
State	:	DC
Zip	:	20007-2521
Country	:	US
Telephone Number	:	202-455-8440
Fax Number	:

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

Provider Enumeration Date	:	01/12/2026
Last Update Date	:	01/12/2026

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Directions to “ OLIVIA R TISA LGSW” Practice Location

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