MEDICARE: LISA MOONEY

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	101Y00000X	Counselor

General Provider Information

NPI Number	:	1982801304
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA MOONEY

Provider Business Mailing Address
First Line	:	PO BOX 458
Second Line	:
City	:	TIGER
State	:	GA
Zip	:	30576-0458
Country	:	US
Telephone Number	:	706-490-2667
Fax Number	:	706-782-1272

Provider Business Practice Location Address
First Line	:	48 TAYLOR VALLEY RD
Second Line	:
City	:	CLAYTON
State	:	GA
Zip	:	30525-5815
Country	:	US
Telephone Number	:	706-490-2667
Fax Number	:	706-782-1272

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

Provider Enumeration Date	:	06/29/2007
Last Update Date	:	07/08/2007

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Directions to “ LISA MOONEY ” Practice Location

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