Provider Demographics
NPI:1477049187
Name:TANGALOS, LISA L (LCSW)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:L
Last Name:TANGALOS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 GABLE CT
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94903-5213
Mailing Address - Country:US
Mailing Address - Phone:415-827-2465
Mailing Address - Fax:
Practice Address - Street 1:10 MILLWOOD ST STE 6
Practice Address - Street 2:
Practice Address - City:MILL VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94941-2064
Practice Address - Country:US
Practice Address - Phone:415-726-8503
Practice Address - Fax:415-726-7503
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-05
Last Update Date:2018-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA80759104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker