Provider Demographics
NPI:1780766253
Name:POWERS, LISA MARIE (MSW LICSW)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:POWERS
Suffix:
Gender:F
Credentials:MSW LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:407 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:MN
Mailing Address - Zip Code:55362-8815
Mailing Address - Country:US
Mailing Address - Phone:763-271-5325
Mailing Address - Fax:
Practice Address - Street 1:1321 13TH ST N
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-2613
Practice Address - Country:US
Practice Address - Phone:320-252-5010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-20
Last Update Date:2016-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN143681041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN199711400Medicaid