MEDICARE: LISA S GONZENBACH 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	1041C0700X	Clinical Social Worker	0969C	AL

General Provider Information

NPI Number	:	1861828519
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LISA S GONZENBACH LLC

Provider Business Mailing Address
First Line	:	3600 WATERMELON RD
Second Line	:	SUITE 202
City	:	NORTHPORT
State	:	AL
Zip	:	35473-5169
Country	:	US
Telephone Number	:	205-750-0181
Fax Number	:

Provider Business Practice Location Address
First Line	:	3600 WATERMELON RD
Second Line	:	SUITE 202
City	:	NORTHPORT
State	:	AL
Zip	:	35473-5169
Country	:	US
Telephone Number	:	205-750-0181
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	LISA GONZENBACH
Credential	:
Telephone Number	:	205-750-0181

Provider Enumeration Date	:	09/25/2013
Last Update Date	:	01/23/2014

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