Provider Demographics
NPI:1174859086
Name:ANZALONE, LISA S (MSW, LCSW)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:S
Last Name:ANZALONE
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:MRS
Other - First Name:LISA
Other - Middle Name:S
Other - Last Name:POLK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW, LCSW
Mailing Address - Street 1:136 MUSSELL LN
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117-3707
Mailing Address - Country:US
Mailing Address - Phone:704-230-7998
Mailing Address - Fax:704-230-1397
Practice Address - Street 1:132 JOE KNOX AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117-9202
Practice Address - Country:US
Practice Address - Phone:704-230-7998
Practice Address - Fax:704-230-1397
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-28
Last Update Date:2016-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0058721041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6007471Medicaid