Provider Demographics
NPI:1871653584
Name:BEVERIDGE, LISA D (LSW)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:D
Last Name:BEVERIDGE
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1605 N CEDAR CREST BLVD STE 411
Mailing Address - Street 2:
Mailing Address - City:ALLENTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18104-2323
Mailing Address - Country:US
Mailing Address - Phone:610-969-1914
Mailing Address - Fax:610-969-3951
Practice Address - Street 1:14351 KUTZTOWN RD
Practice Address - Street 2:
Practice Address - City:FLEETWOOD
Practice Address - State:PA
Practice Address - Zip Code:19522-9273
Practice Address - Country:US
Practice Address - Phone:610-944-8800
Practice Address - Fax:610-944-8213
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2020-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASW122833104100000X
PACW0187561041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1013467000002Medicaid