Provider Demographics
NPI:1396528352
Name:DEFFENBAUGH, LISA L (MSW)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:L
Last Name:DEFFENBAUGH
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 W BERCKMAN ST
Mailing Address - Street 2:
Mailing Address - City:FRUITLAND PARK
Mailing Address - State:FL
Mailing Address - Zip Code:34731-3265
Mailing Address - Country:US
Mailing Address - Phone:352-702-2802
Mailing Address - Fax:
Practice Address - Street 1:301 W BERCKMAN ST
Practice Address - Street 2:
Practice Address - City:FRUITLAND PARK
Practice Address - State:FL
Practice Address - Zip Code:34731-3265
Practice Address - Country:US
Practice Address - Phone:352-702-2802
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-15
Last Update Date:2023-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty