Provider Demographics
NPI:1376767244
Name:PANELO, LISA IERVOLINO (MS, LCSW)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:IERVOLINO
Last Name:PANELO
Suffix:
Gender:F
Credentials:MS, LCSW
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:JARRETT
Other - Last Name:IERVOLINO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, LCSW
Mailing Address - Street 1:2253 CAPE ARBOR DR
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23451-1530
Mailing Address - Country:US
Mailing Address - Phone:757-343-0064
Mailing Address - Fax:
Practice Address - Street 1:4099 FOXWOOD DR
Practice Address - Street 2:SUITE 200
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23462-5222
Practice Address - Country:US
Practice Address - Phone:757-467-8184
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2018-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040065021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1376767244OtherNPI
VA1376767244Medicaid