Provider Demographics
NPI:1952069379
Name:RAIGELUW, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:RAIGELUW
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 1:8610 MERCATOR CT
Mailing Address - Street 2:
Mailing Address - City:PARRISH
Mailing Address - State:FL
Mailing Address - Zip Code:34219-1833
Mailing Address - Country:US
Mailing Address - Phone:808-938-7047
Mailing Address - Fax:
Practice Address - Street 1:8610 MERCATOR CT
Practice Address - Street 2:
Practice Address - City:PARRISH
Practice Address - State:FL
Practice Address - Zip Code:34219-1833
Practice Address - Country:US
Practice Address - Phone:808-938-7047
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-02
Last Update Date:2022-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW192431041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical