Provider Demographics
NPI:1114243649
Name:FLAKES, ALISA LATRICE (LMFT)
Entity Type:Individual
Prefix:
First Name:ALISA
Middle Name:LATRICE
Last Name:FLAKES
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16433 GELDING WAY
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92555-3313
Mailing Address - Country:US
Mailing Address - Phone:951-243-6906
Mailing Address - Fax:
Practice Address - Street 1:769 W BLAINE ST STE A
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507-3970
Practice Address - Country:US
Practice Address - Phone:951-358-6895
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-08
Last Update Date:2010-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 47888106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist