Provider Demographics
NPI:1114707288
Name:NOSHAY PETRO, LISA LEAH SHOSHANNA (MSW)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:LEAH SHOSHANNA
Last Name:NOSHAY PETRO
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:SUSAN
Other - Last Name:COHEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1625 SCHRADER BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90028-6213
Mailing Address - Country:US
Mailing Address - Phone:323-860-3736
Mailing Address - Fax:
Practice Address - Street 1:1625 SCHRADER BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90028-6213
Practice Address - Country:US
Practice Address - Phone:323-860-3736
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-04
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA116737104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA116737OtherBOARD OF BEHAVIORAL SCIENCE
01536011OtherMEDICAL