Provider Demographics
NPI:1407231434
Name:MACIAS, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:MACIAS
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 1:1514 CHERRY AVE
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95125-3803
Mailing Address - Country:US
Mailing Address - Phone:408-406-2939
Mailing Address - Fax:
Practice Address - Street 1:1514 CHERRY AVE
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95125-3803
Practice Address - Country:US
Practice Address - Phone:408-406-2939
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-20
Last Update Date:2021-01-18
Deactivation Date:2018-03-27
Deactivation Code:
Reactivation Date:2021-01-18
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No251S00000XAgenciesCommunity/Behavioral Health