Provider Demographics
NPI:1194186866
Name:GOTTFRIED, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:GOTTFRIED
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:49 BOONE VILLAGE
Mailing Address - Street 2:SUITE #322
Mailing Address - City:ZIONSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46077
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:49 BOONE VILLAGE
Practice Address - Street 2:SUITE #322
Practice Address - City:ZIONSVILLE
Practice Address - State:IN
Practice Address - Zip Code:46077
Practice Address - Country:US
Practice Address - Phone:219-895-6103
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-09
Last Update Date:2016-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1Medicaid