Provider Demographics
NPI:1861828519
Name:LISA S GONZENBACH LLC
Entity Type:Organization
Organization Name:LISA S GONZENBACH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:GONZENBACH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:205-750-0181
Mailing Address - Street 1:3600 WATERMELON RD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:NORTHPORT
Mailing Address - State:AL
Mailing Address - Zip Code:35473-5169
Mailing Address - Country:US
Mailing Address - Phone:205-750-0181
Mailing Address - Fax:
Practice Address - Street 1:3600 WATERMELON RD
Practice Address - Street 2:SUITE 202
Practice Address - City:NORTHPORT
Practice Address - State:AL
Practice Address - Zip Code:35473-5169
Practice Address - Country:US
Practice Address - Phone:205-750-0181
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-25
Last Update Date:2014-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL0969C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty