Provider Demographics
NPI:1063997831
Name:ANDERSON, LISA MICHELE (LSW)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:MICHELE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 E WREN CIR
Mailing Address - Street 2:
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45420-2949
Mailing Address - Country:US
Mailing Address - Phone:937-269-2426
Mailing Address - Fax:
Practice Address - Street 1:1785 BIG HILL RD
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45439-2219
Practice Address - Country:US
Practice Address - Phone:937-264-0084
Practice Address - Fax:937-264-0095
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-27
Last Update Date:2018-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.13033401041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH$$$$$$$$$Medicaid