Provider Demographics
NPI:1053763169
Name:LISA BENTIVENGA LCSW P LLC
Entity type:Organization
Organization Name:LISA BENTIVENGA LCSW P LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LSCW
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:BENTIVENGA
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:813-505-1949
Mailing Address - Street 1:4010 HARBOR LAKE DR
Mailing Address - Street 2:
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33558-9731
Mailing Address - Country:US
Mailing Address - Phone:813-505-1949
Mailing Address - Fax:813-651-5465
Practice Address - Street 1:322 W BEARSS AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33613-1228
Practice Address - Country:US
Practice Address - Phone:813-505-1949
Practice Address - Fax:813-651-5465
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-13
Last Update Date:2017-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW112701041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty