Provider Demographics
NPI:1063415909
Name:AMODIO, LISA (LISW-CP, LCSW-R)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:AMODIO
Suffix:
Gender:F
Credentials:LISW-CP, LCSW-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 740013
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-0013
Mailing Address - Country:US
Mailing Address - Phone:312-733-9730
Mailing Address - Fax:
Practice Address - Street 1:5110 FAIRFIELD RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-4323
Practice Address - Country:US
Practice Address - Phone:803-893-7019
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-24
Last Update Date:2024-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC120951041C0700X
NY0542681041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
P90172Medicare UPIN