Provider Demographics
NPI:1437685666
Name:GALVAN, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:GALVAN
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 1:2550 E. FOOTHILL, 2ND FL,
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91107
Mailing Address - Country:US
Mailing Address - Phone:626-744-5230
Mailing Address - Fax:
Practice Address - Street 1:3316 W BEVERLY BLVD
Practice Address - Street 2:
Practice Address - City:MONTEBELLO
Practice Address - State:CA
Practice Address - Zip Code:90640-1537
Practice Address - Country:US
Practice Address - Phone:323-722-4529
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-09
Last Update Date:2017-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YA0400X
CAR1260480817171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA02768010OtherDRUG MEDI-CAL