Provider Demographics
NPI:1417143777
Name:PERRINE, LISA BOAL (PHD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:BOAL
Last Name:PERRINE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1329 HOWE AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95825-3363
Mailing Address - Country:US
Mailing Address - Phone:916-929-5455
Mailing Address - Fax:
Practice Address - Street 1:1329 HOWE AVE STE 201
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95825-3363
Practice Address - Country:US
Practice Address - Phone:916-929-5455
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-20
Last Update Date:2007-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY15344103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPL153440Medicare PIN