1063501450 NPI number — LISA BETH ANGER LCSW

Table of content: LISA BETH ANGER LCSW (NPI 1063501450)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063501450 NPI number — LISA BETH ANGER LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ANGER
Provider First Name:
LISA
Provider Middle Name:
BETH
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WURZBURG
Provider Other First Name:
LISA
Provider Other Middle Name:
BETH
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
CSW
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1063501450
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/22/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
160 TIMBERLANE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATHENS
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30606-2400
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-540-6249
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
500 N MILLEDGE AVE
Provider Second Line Business Practice Location Address:
SUITE 219
Provider Business Practice Location Address City Name:
ATHENS
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30601-3810
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-540-6249
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/12/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  2474 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 833623732A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".