Provider Demographics
NPI:1831654052
Name:VARGO, LISA D (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:D
Last Name:VARGO
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 1:6101 ROBBIE LANE
Mailing Address - Street 2:
Mailing Address - City:CRESTVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:32539
Mailing Address - Country:US
Mailing Address - Phone:850-603-9494
Mailing Address - Fax:
Practice Address - Street 1:350 PLANTATION CLUB PKWY
Practice Address - Street 2:
Practice Address - City:FRUIT COVE
Practice Address - State:FL
Practice Address - Zip Code:32259-2994
Practice Address - Country:US
Practice Address - Phone:850-111-1111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-01
Last Update Date:2019-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW164151041C0700X
FLISW11721104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLSW16415OtherLCSW