Provider Demographics
NPI:1164785341
Name:PROBST, LISA MARY (LMFT 90976)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:MARY
Last Name:PROBST
Suffix:
Gender:F
Credentials:LMFT 90976
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:393 E WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91188-0001
Mailing Address - Country:US
Mailing Address - Phone:562-490-7638
Mailing Address - Fax:562-490-7601
Practice Address - Street 1:5150 E PACIFIC COAST HWY STE 100
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90804-3394
Practice Address - Country:US
Practice Address - Phone:562-490-7638
Practice Address - Fax:562-490-7601
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA90976106H00000X, 106H00000X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health