Provider Demographics
NPI:1164869095
Name:LAWRENCE, MAKISHA ALYCE (PSYD)
Entity Type:Individual
Prefix:
First Name:MAKISHA
Middle Name:ALYCE
Last Name:LAWRENCE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2910 S ARCHIBALD AVE
Mailing Address - Street 2:SUITE A # 129
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91761-7323
Mailing Address - Country:US
Mailing Address - Phone:818-618-3182
Mailing Address - Fax:
Practice Address - Street 1:2910 S ARCHIBALD AVE
Practice Address - Street 2:SUITE A # 129
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91761-7323
Practice Address - Country:US
Practice Address - Phone:818-618-3182
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-01
Last Update Date:2013-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY24152103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist