Basic Information
| Provider Information | |||||||||
| NPI: | 1568470367 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | YANKU | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | G | ||||||||
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| Credential: | LICSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4014 CONNECTION POINT BLVD | ||||||||
| Address2: | STE C | ||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282120332 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4017384300 | ||||||||
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| Practice Location | |||||||||
| Address1: | 50 HEALTH LN | ||||||||
| Address2: | |||||||||
| City: | WARWICK | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028862711 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4017384300 | ||||||||
| FaxNumber: | 4017388634 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2006 | ||||||||
| LastUpdateDate: | 04/05/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | C009243 | NC | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | ISW00498 | RI | N | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | LY10977 | 05 | RI | MEDICAID | 30118-1 | 01 | RI | BLUE CROSS | OTHER | 62-67493 | 01 | RI | UBH | OTHER | 408503 | 01 | RI | BLUE CHIP | OTHER |