Provider Demographics
NPI:1467489641
Name:CLEVINGER, LISA E (LCSW)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:E
Last Name:CLEVINGER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2621 PROMENADE PKWY
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23113-1431
Mailing Address - Country:US
Mailing Address - Phone:804-594-7046
Mailing Address - Fax:804-594-2635
Practice Address - Street 1:2621 PROMENADE PKWY
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23113-1431
Practice Address - Country:US
Practice Address - Phone:804-594-7046
Practice Address - Fax:804-594-2635
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040036581041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA178404OtherANTHEM BLUE SHIELD
VA007614V65Medicare ID - Type Unspecified