Provider Demographics
NPI:1477690162
Name:COLVIN-ELLISON, LISA S
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:S
Last Name:COLVIN-ELLISON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:SUSANNE
Other - Last Name:COLVIN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:2425 BISSO LN
Mailing Address - Street 2:#235
Mailing Address - City:CONCORD
Mailing Address - State:CA
Mailing Address - Zip Code:94520-4897
Mailing Address - Country:US
Mailing Address - Phone:925-646-5181
Mailing Address - Fax:
Practice Address - Street 1:2425 BISSO LN
Practice Address - Street 2:#235
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94520-4897
Practice Address - Country:US
Practice Address - Phone:925-646-5181
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-31
Last Update Date:2023-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34604106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist