Provider Demographics
NPI:1437417243
Name:KORNEGAY, LISA MICHELLE (LCAS)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MICHELLE
Last Name:KORNEGAY
Suffix:
Gender:F
Credentials:LCAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:877 E GANNON AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:ZEBULON
Mailing Address - State:NC
Mailing Address - Zip Code:27597-9445
Mailing Address - Country:US
Mailing Address - Phone:314-496-2568
Mailing Address - Fax:919-832-0825
Practice Address - Street 1:877 E GANNON AVE STE 103
Practice Address - Street 2:
Practice Address - City:ZEBULON
Practice Address - State:NC
Practice Address - Zip Code:27597-9445
Practice Address - Country:US
Practice Address - Phone:314-496-2568
Practice Address - Fax:919-832-0825
Is Sole Proprietor?:No
Enumeration Date:2012-04-30
Last Update Date:2020-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1921101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)