Provider Demographics
NPI:1235539784
Name:TULLY, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:TULLY
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 1:10725 INTERNATIONAL DR
Mailing Address - Street 2:
Mailing Address - City:RANCHO CORDOVA
Mailing Address - State:CA
Mailing Address - Zip Code:95670-7967
Mailing Address - Country:US
Mailing Address - Phone:949-267-0201
Mailing Address - Fax:949-267-0299
Practice Address - Street 1:2500 REDHILL AVE
Practice Address - Street 2:STE 290A
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-5518
Practice Address - Country:US
Practice Address - Phone:949-267-0201
Practice Address - Fax:949-267-0299
Is Sole Proprietor?:No
Enumeration Date:2014-09-02
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY26013103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist