Provider Demographics
NPI:1639219751
Name:LIS, MARCIA K (LCSW)
Entity Type:Individual
Prefix:
First Name:MARCIA
Middle Name:K
Last Name:LIS
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 1:410 FOULK RD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19803-3820
Mailing Address - Country:US
Mailing Address - Phone:302-762-2285
Mailing Address - Fax:
Practice Address - Street 1:1601 CONCORD PIKE
Practice Address - Street 2:SUITES 92-100
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19803-3612
Practice Address - Country:US
Practice Address - Phone:302-409-3434
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2014-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEQ1-00007901041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE100039274Medicaid