Provider Demographics
NPI:1720348493
Name:KOVITCH, LISA S (MA, BCBA, LPC)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:S
Last Name:KOVITCH
Suffix:
Gender:F
Credentials:MA, BCBA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6212 NORTHLAKE CIR NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30345-2848
Mailing Address - Country:US
Mailing Address - Phone:570-982-9436
Mailing Address - Fax:678-669-2632
Practice Address - Street 1:6212 NORTHLAKE CIR NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30345-2848
Practice Address - Country:US
Practice Address - Phone:570-982-9436
Practice Address - Fax:678-669-2632
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-29
Last Update Date:2014-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC007330101YP2500X
103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst