Provider Demographics
NPI:1568470367
Name:YANKU, LISA GOODMAN (LCSW)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:GOODMAN
Last Name:YANKU
Suffix:
Gender:
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5730 EXECUTIVE DR STE 230
Mailing Address - Street 2:
Mailing Address - City:CATONSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21228-1762
Mailing Address - Country:US
Mailing Address - Phone:704-443-6250
Mailing Address - Fax:
Practice Address - Street 1:2030 WINDSOR RUN LN
Practice Address - Street 2:
Practice Address - City:MATTHEWS
Practice Address - State:NC
Practice Address - Zip Code:28105-0054
Practice Address - Country:US
Practice Address - Phone:704-443-6250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2025-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIISW004981041C0700X
NCC0092431041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI62-67493OtherUBH
RI408503OtherBLUE CHIP
RI30118-1OtherBLUE CROSS
RILY10977Medicaid