Provider Demographics
NPI:1346301942
Name:WALL, LISA H (MFT)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:H
Last Name:WALL
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16480 HARBOR BLVD STE 104
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-1361
Mailing Address - Country:US
Mailing Address - Phone:714-420-8756
Mailing Address - Fax:714-775-1026
Practice Address - Street 1:16480 HARBOR BLVD STE 104
Practice Address - Street 2:
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-1361
Practice Address - Country:US
Practice Address - Phone:714-420-8756
Practice Address - Fax:714-775-1026
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC30768106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist