Basic Information
| Provider Information | |||||||||
| NPI: | 1073764965 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GEORGE | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | SHEA | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MSW | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 405 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | DANBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 068104710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037434412 | ||||||||
| FaxNumber: | 1203738118 | ||||||||
| Practice Location | |||||||||
| Address1: | 405 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | DANBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 068104710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037434412 | ||||||||
| FaxNumber: | 1203738118 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/09/2008 | ||||||||
| LastUpdateDate: | 11/14/2013 | ||||||||
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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 | 104100000X | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 004040655 | 05 | CT | MEDICAID |