Provider Demographics
NPI:1356675615
Name:SIMMONS-SLATER, LISA MARIE (MFT)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:MARIE
Last Name:SIMMONS-SLATER
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 1:2419 DEER TREE COURT
Mailing Address - Street 2:
Mailing Address - City:MARTINEZ
Mailing Address - State:CA
Mailing Address - Zip Code:94553
Mailing Address - Country:US
Mailing Address - Phone:925-395-1303
Mailing Address - Fax:925-387-5154
Practice Address - Street 1:3184 OLD TUNNEL ROAD, SUITE A
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:CA
Practice Address - Zip Code:94549
Practice Address - Country:US
Practice Address - Phone:925-395-1301
Practice Address - Fax:925-387-5154
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-18
Last Update Date:2019-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC36871106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1356675615OtherNON-MEDICARE