Basic Information
| Provider Information | |||||||||
| NPI: | 1588796668 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | INNES | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | A.M. | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | CSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1351 NEWTOWN PIKE | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405111217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592531686 | ||||||||
| FaxNumber: | 8592542743 | ||||||||
| Practice Location | |||||||||
| Address1: | 845 ANGLIANA AVE | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405083146 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593239321 | ||||||||
| FaxNumber: | 8592575232 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/12/2007 | ||||||||
| LastUpdateDate: | 03/16/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/16/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 3569 | KY | N | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | 256308 | KY | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 30615058 | 05 | KY | MEDICAID |