Provider Demographics
NPI:1760737274
Name:AUTRY, LISA LYNNE (M SW, ACSW)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:LYNNE
Last Name:AUTRY
Suffix:
Gender:F
Credentials:M SW, ACSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4001 ROSEWOOD DRIVE
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47404
Mailing Address - Country:US
Mailing Address - Phone:812-929-2747
Mailing Address - Fax:
Practice Address - Street 1:2125 16TH STREET
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:IN
Practice Address - Zip Code:47421
Practice Address - Country:US
Practice Address - Phone:812-275-4053
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-20
Last Update Date:2012-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34003553A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical