Provider Demographics
NPI:1013024660
Name:BENTON, LISA (LCSW)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:BENTON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5701 S MO PAC EXPY APT 134
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78749-1434
Mailing Address - Country:US
Mailing Address - Phone:512-442-7578
Mailing Address - Fax:
Practice Address - Street 1:2403 W BEN WHITE BLVD
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78704-7534
Practice Address - Country:US
Practice Address - Phone:512-707-2782
Practice Address - Fax:512-707-2783
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX35488104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8G0615Medicare ID - Type Unspecified