1932827730 NPI number — MS. LISA JACQUELINE WEBER LGSW

Table of content: MS. LISA JACQUELINE WEBER LGSW (NPI 1932827730)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932827730 NPI number — MS. LISA JACQUELINE WEBER LGSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WEBER
Provider First Name:
LISA
Provider Middle Name:
JACQUELINE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
LGSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1932827730
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/17/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

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

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5700 BOTTINEAU BLVD STE 210
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CRYSTAL
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55429-3184
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
763-330-2774
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/17/2022

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:  28873 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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