Provider Demographics
NPI:1124202692
Name:EVERSON, LISA DANIELLE (MFT)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:DANIELLE
Last Name:EVERSON
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:950 N RAMONA BLVD STE 2
Mailing Address - Street 2:
Mailing Address - City:SAN JACINTO
Mailing Address - State:CA
Mailing Address - Zip Code:92582-2571
Mailing Address - Country:US
Mailing Address - Phone:951-358-4625
Mailing Address - Fax:
Practice Address - Street 1:950 N RAMONA BLVD STE 2
Practice Address - Street 2:
Practice Address - City:SAN JACINTO
Practice Address - State:CA
Practice Address - Zip Code:92582-2571
Practice Address - Country:US
Practice Address - Phone:951-487-2674
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-19
Last Update Date:2021-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 44486106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist