MEDICARE: DR. LISA NUSSBAUM LPC

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	101YP2500X	Professional Counselor	17417	TX

General Provider Information

NPI Number	:	1982852273
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LISA NUSSBAUM LPC

Provider Business Mailing Address
First Line	:	2200 W ROSEDALE ST. S SUITE A
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76110
Country	:	US
Telephone Number	:	817-368-9955
Fax Number	:	817-926-7381

Provider Business Practice Location Address
First Line	:	2200 W ROSEDALE ST S
Second Line	:	SUITE A
City	:	FORT WORTH
State	:	TX
Zip	:	76110-1170
Country	:	US
Telephone Number	:	817-368-9955
Fax Number	:	817-926-7381

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

Provider Enumeration Date	:	08/29/2008
Last Update Date	:	08/29/2008

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