Provider Demographics
NPI:1114938222
Name:GWALTNEY, LISA M (MSW LCSW)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:GWALTNEY
Suffix:
Gender:F
Credentials:MSW LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 MULBERRY ST
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47713-1230
Mailing Address - Country:US
Mailing Address - Phone:812-423-7791
Mailing Address - Fax:812-422-7558
Practice Address - Street 1:4001 JOHN ST
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47714-0216
Practice Address - Country:US
Practice Address - Phone:812-473-3144
Practice Address - Fax:812-422-7558
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2010-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34003974A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000181765OtherANTHEM
IN100240880Medicaid
IN000000181765OtherANTHEM