Provider Demographics
NPI:1720359409
Name:COVENTRY, LISA D
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:D
Last Name:COVENTRY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 E OAKLAND PARK BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:OAKLAND PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33334-4400
Mailing Address - Country:US
Mailing Address - Phone:954-599-2047
Mailing Address - Fax:
Practice Address - Street 1:1400 E OAKLAND PARK BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:OAKLAND PARK
Practice Address - State:FL
Practice Address - Zip Code:33334-4400
Practice Address - Country:US
Practice Address - Phone:954-599-2047
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-26
Last Update Date:2014-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW68391041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical