Provider Demographics
NPI:1972058238
Name:GEORGE, LISA
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:GEORGE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18011 S TAMIAMI TRL # 16-52F
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33908-4697
Mailing Address - Country:US
Mailing Address - Phone:303-898-6301
Mailing Address - Fax:
Practice Address - Street 1:18050 S TAMIAMI TRL
Practice Address - Street 2:LOT 140
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908-4658
Practice Address - Country:US
Practice Address - Phone:303-898-6301
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-16
Last Update Date:2016-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool