Provider Demographics
NPI:1043342140
Name:POLISANO, LISA GRACE
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:GRACE
Last Name:POLISANO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4798 SULLIVAN ST
Mailing Address - Street 2:#103
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93003-8213
Mailing Address - Country:US
Mailing Address - Phone:818-929-6586
Mailing Address - Fax:
Practice Address - Street 1:975 FLYNN RD
Practice Address - Street 2:
Practice Address - City:CAMARILLO
Practice Address - State:CA
Practice Address - Zip Code:93012-8704
Practice Address - Country:US
Practice Address - Phone:805-914-1439
Practice Address - Fax:805-482-0987
Is Sole Proprietor?:No
Enumeration Date:2007-03-12
Last Update Date:2009-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA46922106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist