Provider Demographics
NPI:1396973988
Name:TAYLOR, LISA D (PHD, TLP, LCSW)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:D
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:PHD, TLP, LCSW
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 652
Mailing Address - Street 2:
Mailing Address - City:AVONDALE ESTATES
Mailing Address - State:GA
Mailing Address - Zip Code:30002-0652
Mailing Address - Country:US
Mailing Address - Phone:678-517-9984
Mailing Address - Fax:404-292-9424
Practice Address - Street 1:652 PO BOX
Practice Address - Street 2:
Practice Address - City:AVONDALE ESTATES
Practice Address - State:GA
Practice Address - Zip Code:30002
Practice Address - Country:US
Practice Address - Phone:678-517-9984
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-23
Last Update Date:2025-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA4007191041S0200X
GACSW0034931041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA101YMO800XMedicaid
GA101YMO800XMedicaid