Provider Demographics
NPI:1245750223
Name:HERTENSTEIN, LISA MARIE
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:HERTENSTEIN
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 1:4814 HEARTHWOOD CT
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95206-6305
Mailing Address - Country:US
Mailing Address - Phone:209-601-2255
Mailing Address - Fax:
Practice Address - Street 1:955 W CENTER ST
Practice Address - Street 2:
Practice Address - City:MANTECA
Practice Address - State:CA
Practice Address - Zip Code:95337-7300
Practice Address - Country:US
Practice Address - Phone:209-239-9600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-21
Last Update Date:2017-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)