Provider Demographics
NPI:1275983462
Name:GASKIN, LISA (MA)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:GASKIN
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 W AVENIDA GAVIOTA
Mailing Address - Street 2:
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92672-5442
Mailing Address - Country:US
Mailing Address - Phone:949-291-1505
Mailing Address - Fax:
Practice Address - Street 1:208 W AVENIDA GAVIOTA
Practice Address - Street 2:
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92672-5442
Practice Address - Country:US
Practice Address - Phone:949-291-1505
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-17
Last Update Date:2016-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA92543106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist