Provider Demographics
NPI:1346677176
Name:MADDOX, LISA (LMFT, LPCC)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:MADDOX
Suffix:
Gender:F
Credentials:LMFT, LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2973
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92859-0973
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1107 E CHAPMAN AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92866-2101
Practice Address - Country:US
Practice Address - Phone:714-348-8161
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-11
Last Update Date:2014-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA187101YP2500X
CA49130106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional