Provider Demographics
NPI:1417122292
Name:GRASSLE, LISA VICTORIA (MFT)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:VICTORIA
Last Name:GRASSLE
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:PO BOX 2212
Mailing Address - Street 2:
Mailing Address - City:NIPOMO
Mailing Address - State:CA
Mailing Address - Zip Code:93444-2212
Mailing Address - Country:US
Mailing Address - Phone:805-929-5582
Mailing Address - Fax:
Practice Address - Street 1:454 MERCURY DR
Practice Address - Street 2:
Practice Address - City:NIPOMO
Practice Address - State:CA
Practice Address - Zip Code:93444-9614
Practice Address - Country:US
Practice Address - Phone:805-929-5582
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-23
Last Update Date:2008-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC31818106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist