Provider Demographics
NPI:1033520572
Name:CASTANEDA, LISA K (MFT)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:K
Last Name:CASTANEDA
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:DESTRO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:955 W CENTER ST STE 9
Mailing Address - Street 2:
Mailing Address - City:MANTECA
Mailing Address - State:CA
Mailing Address - Zip Code:95337-7327
Mailing Address - Country:US
Mailing Address - Phone:209-596-2377
Mailing Address - Fax:
Practice Address - Street 1:955 W CENTER ST STE 9
Practice Address - Street 2:
Practice Address - City:MANTECA
Practice Address - State:CA
Practice Address - Zip Code:95337-7327
Practice Address - Country:US
Practice Address - Phone:209-596-2377
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-19
Last Update Date:2019-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF 75434101YP2500X
CALMFT100353106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional