Provider Demographics
NPI:1316560279
Name:LIZAMA, LYNETTE MARIE SAN AGUSTIN
Entity Type:Individual
Prefix:
First Name:LYNETTE MARIE
Middle Name:SAN AGUSTIN
Last Name:LIZAMA
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 1:7621 PITCHER PT APT 201
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN
Mailing Address - State:CO
Mailing Address - Zip Code:80817-4816
Mailing Address - Country:US
Mailing Address - Phone:808-781-5776
Mailing Address - Fax:
Practice Address - Street 1:3535 PARKMOOR VILLAGE DR
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80917-5292
Practice Address - Country:US
Practice Address - Phone:719-574-7688
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-26
Last Update Date:2020-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst