Provider Demographics
NPI:1932827730
Name:WEBER, LISA JACQUELINE (LGSW)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:JACQUELINE
Last Name:WEBER
Suffix:
Gender:F
Credentials:LGSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4417 2ND AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55419-5103
Mailing Address - Country:US
Mailing Address - Phone:612-806-1653
Mailing Address - Fax:
Practice Address - Street 1:5700 BOTTINEAU BLVD STE 210
Practice Address - Street 2:
Practice Address - City:CRYSTAL
Practice Address - State:MN
Practice Address - Zip Code:55429-3184
Practice Address - Country:US
Practice Address - Phone:763-330-2774
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-17
Last Update Date:2022-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN288731041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical