Provider Demographics
NPI:1376176578
Name:TANNEHILL, LISA MARIE
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:TANNEHILL
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 1:3789 BOULDER CANYON DR
Mailing Address - Street 2:
Mailing Address - City:CASTRO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94552-5422
Mailing Address - Country:US
Mailing Address - Phone:510-316-8546
Mailing Address - Fax:
Practice Address - Street 1:851 FREMONT AVE STE 99
Practice Address - Street 2:
Practice Address - City:LOS ALTOS
Practice Address - State:CA
Practice Address - Zip Code:94024-5602
Practice Address - Country:US
Practice Address - Phone:510-316-8546
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-15
Last Update Date:2021-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA126325106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty