Provider Demographics
NPI:1104182823
Name:COREY, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:COREY
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:PO BOX 902
Mailing Address - Street 2:
Mailing Address - City:IDYLLWILD
Mailing Address - State:CA
Mailing Address - Zip Code:92549-0902
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:41750 RANCHO LAS PALMAS DR STE K-1
Practice Address - Street 2:
Practice Address - City:RANCHO MIRAGE
Practice Address - State:CA
Practice Address - Zip Code:92270-5514
Practice Address - Country:US
Practice Address - Phone:760-459-2282
Practice Address - Fax:951-468-4432
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-06
Last Update Date:2019-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT50323106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist