Provider Demographics
NPI:1255651931
Name:POVICH, LISA (LCSW-C)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:
Last Name:POVICH
Suffix:
Gender:F
Credentials:LCSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11321 BRANDY HALL LN
Mailing Address - Street 2:
Mailing Address - City:NORTH POTOMAC
Mailing Address - State:MD
Mailing Address - Zip Code:20878-2533
Mailing Address - Country:US
Mailing Address - Phone:301-279-0463
Mailing Address - Fax:
Practice Address - Street 1:9021 SHADY GROVE CT
Practice Address - Street 2:
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20877-1301
Practice Address - Country:US
Practice Address - Phone:301-590-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-04
Last Update Date:2010-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD107641041C0700X
DCLC3033131041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical