Provider Demographics
NPI:1114434040
Name:AHEARNE, MARIA LISA
Entity Type:Individual
Prefix:
First Name:MARIA LISA
Middle Name:
Last Name:AHEARNE
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 1:2538 17TH AVE
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94116-3001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1801 BUSH ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94109-5239
Practice Address - Country:US
Practice Address - Phone:415-580-1639
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-30
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103986106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA103986OtherLMFT