Provider Demographics
NPI:1376645473
Name:LISTER, FANITA MARIAN (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:FANITA
Middle Name:MARIAN
Last Name:LISTER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4712 ADMIRALTY WAY
Mailing Address - Street 2:#633
Mailing Address - City:MARINA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90292-6905
Mailing Address - Country:US
Mailing Address - Phone:310-822-9221
Mailing Address - Fax:
Practice Address - Street 1:2659 TOWNSGATE RD
Practice Address - Street 2:#201
Practice Address - City:WESTLAKE VILLAGE
Practice Address - State:CA
Practice Address - Zip Code:91361-2710
Practice Address - Country:US
Practice Address - Phone:805-495-0598
Practice Address - Fax:805-381-9140
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS110861041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1321432Medicaid
SW11086Medicare ID - Type Unspecified
CA1321432Medicaid