Provider Demographics
NPI:1457762163
Name:LISA D COVENTRY
Entity type:Organization
Organization Name:LISA D COVENTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:D
Authorized Official - Last Name:COVENTRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-599-2047
Mailing Address - Street 1:1400 E OAKLAND PARK BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:OAKLAND PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33334-4400
Mailing Address - Country:US
Mailing Address - Phone:954-599-2047
Mailing Address - Fax:
Practice Address - Street 1:1400 E OAKLAND PARK BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:OAKLAND PARK
Practice Address - State:FL
Practice Address - Zip Code:33334-4400
Practice Address - Country:US
Practice Address - Phone:954-599-2047
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-15
Last Update Date:2014-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW68391041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty