Provider Demographics
NPI:1508143702
Name:BENNER, LISA (LCSW, LISAC)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:
Last Name:BENNER
Suffix:
Gender:F
Credentials:LCSW, LISAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1057 N PARKSIDE DR
Mailing Address - Street 2:#425
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85281-3153
Mailing Address - Country:US
Mailing Address - Phone:602-277-5551
Mailing Address - Fax:
Practice Address - Street 1:1057 N PARKSIDE DR
Practice Address - Street 2:#425
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85281-3153
Practice Address - Country:US
Practice Address - Phone:602-277-5551
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-16
Last Update Date:2011-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLCSW126091041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical