Provider Demographics
NPI:1043786130
Name:POOCH, LISIANE
Entity Type:Individual
Prefix:
First Name:LISIANE
Middle Name:
Last Name:POOCH
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 1:11200 WAPLES MILL RD STE 202
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-7407
Mailing Address - Country:US
Mailing Address - Phone:571-639-9276
Mailing Address - Fax:
Practice Address - Street 1:11240 WAPLES MILL RD STE 101
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-6078
Practice Address - Country:US
Practice Address - Phone:571-639-9276
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-16
Last Update Date:2021-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician