MEDICARE: LISA RENEE CHANDLER 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	LCSW-18404	AZ

General Provider Information

NPI Number	:	1750906111
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA RENEE CHANDLER LCSW

Provider Business Mailing Address
First Line	:	3845 E GREENWAY RD UNIT 102
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85032-4676
Country	:	US
Telephone Number	:	480-392-7630
Fax Number	:

Provider Business Practice Location Address
First Line	:	1125 W JACKSON ST
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85007-3110
Country	:	US
Telephone Number	:	480-392-7630
Fax Number	:

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

Provider Enumeration Date	:	06/11/2020
Last Update Date	:	06/11/2020

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