Provider Demographics
NPI:1417465709
Name:GAYOU, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:GAYOU
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 1:350 MARINA DR APT 10
Mailing Address - Street 2:
Mailing Address - City:SEAL BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90740-6064
Mailing Address - Country:US
Mailing Address - Phone:562-833-3563
Mailing Address - Fax:562-833-3563
Practice Address - Street 1:350 MARINA DR APT 10
Practice Address - Street 2:
Practice Address - City:SEAL BEACH
Practice Address - State:CA
Practice Address - Zip Code:90740-6064
Practice Address - Country:US
Practice Address - Phone:562-833-3563
Practice Address - Fax:562-833-3563
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-20
Last Update Date:2018-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-14-16576103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst