Provider Demographics
NPI:1750471041
Name:GONZENBACH, LISA SAFF (MSW)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:SAFF
Last Name:GONZENBACH
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 1:3600 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:205-348-2401
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:205-348-2401
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL0969C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL051550886Medicare ID - Type UnspecifiedMEDICARE
AL51043942Medicare UPIN