Provider Demographics
NPI:1407042914
Name:ROSEQUIST, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:ROSEQUIST
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 1:1260 N DUTTON AVE
Mailing Address - Street 2:SUITE 225
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95401-4659
Mailing Address - Country:US
Mailing Address - Phone:619-917-8858
Mailing Address - Fax:
Practice Address - Street 1:1260 N DUTTON AVE
Practice Address - Street 2:SUITE 225
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95401-4659
Practice Address - Country:US
Practice Address - Phone:619-917-8858
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-18
Last Update Date:2011-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 24622103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical