Provider Demographics
NPI:1588796668
Name:INNES, LISA AM (CSW)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:AM
Last Name:INNES
Suffix:
Gender:F
Credentials:CSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1351 NEWTOWN PIKE
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40511-1217
Mailing Address - Country:US
Mailing Address - Phone:859-253-1686
Mailing Address - Fax:859-254-2743
Practice Address - Street 1:845 ANGLIANA AVE
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40508-3146
Practice Address - Country:US
Practice Address - Phone:859-323-9321
Practice Address - Fax:859-257-5232
Is Sole Proprietor?:No
Enumeration Date:2007-03-12
Last Update Date:2022-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3569104100000X
KY2563081041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY30615058Medicaid