MEDICARE: MS. LISA JACQUELINE WEBER 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	1041C0700X	Clinical Social Worker	28873	MN

General Provider Information

NPI Number	:	1932827730
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. LISA JACQUELINE WEBER LGSW

Provider Business Mailing Address
First Line	:	4417 2ND AVE S
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55419-5103
Country	:	US
Telephone Number	:	612-806-1653
Fax Number	:

Provider Business Practice Location Address
First Line	:	5700 BOTTINEAU BLVD STE 210
Second Line	:
City	:	CRYSTAL
State	:	MN
Zip	:	55429-3184
Country	:	US
Telephone Number	:	763-330-2774
Fax Number	:

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

Provider Enumeration Date	:	08/17/2022
Last Update Date	:	08/17/2022

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