Provider Demographics
NPI:1598765257
Name:REARDON, LISA JOAN (LICSW)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:JOAN
Last Name:REARDON
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:JOAN
Other - Last Name:REARDON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:415 MICHIGAN AVE NE STE 20
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20017-4500
Mailing Address - Country:US
Mailing Address - Phone:202-321-3781
Mailing Address - Fax:
Practice Address - Street 1:415 MICHIGAN AVE NE STE 20
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20017-4500
Practice Address - Country:US
Practice Address - Phone:202-321-3781
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-26
Last Update Date:2024-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCLC3019951041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC6210-0001OtherBCBS CARE FIRST
MDQI18LJOtherCARE FIRST PIN
MD593365000OtherPROVIDER MIS#
MD100032383001OtherAPS PROVIDER #
MD593365000OtherPROVIDER MIS#