Lisa Wallace, LCSW, LCDC

Primary specialty

Clinical Social WorkerTaxonomy code 1041C0700X

License

58545 Issued in TX

Practice address

2903 Gabriel View Dr
Georgetown, TX 78628-2707

Phone

(512) 869-9254

Fax

(512) 863-6833

NPI assigned

Oct 19, 2018

Sex

Female

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Medicare fee-for-service enrollment

Enrolled in TX

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: No
• Power mobility devices: No
• Hospice: No

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

State licenses

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Grow Healthcare Group PA

  • Mental Health Counselor
  • Miami, FL
  • NPI 1245845932

  Clinical, TX

  Medicare reassignment NPD

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1539907200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1635379200000",
    "number": "1760958458",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2903 GABRIEL VIEW DR",
            "city": "GEORGETOWN",
            "state": "TX",
            "postal_code": "786282707",
            "telephone_number": "512-869-9254"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2903 GABRIEL VIEW DR",
            "city": "GEORGETOWN",
            "state": "TX",
            "postal_code": "786282707",
            "telephone_number": "512-869-9254",
            "fax_number": "512-863-6833"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WALLACE",
        "first_name": "LISA",
        "credential": "LCSW, LCDC",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2018-10-19",
        "last_updated": "2021-10-28",
        "certification_date": "2021-10-28",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1041C0700X",
            "taxonomy_group": "",
            "desc": "Social Worker, Clinical",
            "state": "TX",
            "license": "58545",
            "primary": true
        },
        {
            "code": "101YA0400X",
            "taxonomy_group": "",
            "desc": "Counselor, Addiction (Substance Use Disorder)",
            "state": "TX",
            "license": "12442",
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Walgreen Co
• Walgreen Co
• Devon Walker
• Jessica June Walker, OTR
• Kelly Walker
• Wallflower Therapy, LLC
• Victoria Diane Wallin
• Dharshini Wallooppillai, M.D.
• Holly Jean Wallraff, LCSW
• Leah Walter, LPC

• Clinical Social Worker in Georgetown, TX
• Providers in Georgetown, TX by specialty
• Clinical Social Worker in Texas

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 28, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.