Provider Demographics
NPI:1346704368
Name:MYRUSKI, LISA MARIE (MA, CADC-II)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:MYRUSKI
Suffix:
Gender:F
Credentials:MA, CADC-II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2815 SANTA CLARA AVE
Mailing Address - Street 2:
Mailing Address - City:ALAMEDA
Mailing Address - State:CA
Mailing Address - Zip Code:94501-3013
Mailing Address - Country:US
Mailing Address - Phone:646-226-2333
Mailing Address - Fax:
Practice Address - Street 1:1516 OAK ST STE 310
Practice Address - Street 2:
Practice Address - City:ALAMEDA
Practice Address - State:CA
Practice Address - Zip Code:94501-2958
Practice Address - Country:US
Practice Address - Phone:510-255-2156
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-23
Last Update Date:2019-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARA8820917101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)