Basic Information
| Provider Information | |||||||||
| NPI: | 1083831911 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANDREUCCI | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MISS | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1872 MONTREAL RD | ||||||||
| Address2: | |||||||||
| City: | TUCKER | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300845709 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704953396 | ||||||||
| FaxNumber: | 7704952307 | ||||||||
| Practice Location | |||||||||
| Address1: | 975 JOHNSON FERRY RD NE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303421619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4042564777 | ||||||||
| FaxNumber: | 4042565515 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/20/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | CSW003795 | GA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | CSW003795 | 01 | GA | LCSW LICENSE | OTHER |