Basic Information
| Provider Information | |||||||||
| NPI: | 1073050118 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PAVLIK | ||||||||
| FirstName: | LISA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7175 COLUMBIA GATEWAY DR | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210462534 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 7175 COLUMBIA GATEWAY DR STE A | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210462536 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8883445977 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/27/2017 | ||||||||
| LastUpdateDate: | 10/12/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | LBA493 | MD | N | Behavioral Health & Social Service Providers | Behavioral Analyst | 106S00000X | MD | N | 103K00000X | LBA493 | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.