Provider Demographics
NPI:1003327933
Name:IBEKWE, LISA (LCSW)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:IBEKWE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3001 BRASS DR
Mailing Address - Street 2:
Mailing Address - City:AUSTELL
Mailing Address - State:GA
Mailing Address - Zip Code:30106-1043
Mailing Address - Country:US
Mailing Address - Phone:678-717-9119
Mailing Address - Fax:
Practice Address - Street 1:1091 OVERLOOK PKWY
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210
Practice Address - Country:US
Practice Address - Phone:470-242-6140
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-18
Last Update Date:2020-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMSW0073591041C0700X
GACSW0069761041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical