Provider Demographics
NPI:1558002378
Name:WHITTEN, LISA KATHLEEN (APCC)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:KATHLEEN
Last Name:WHITTEN
Suffix:
Gender:F
Credentials:APCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:193 BLUE RAVINE RD STE 220
Mailing Address - Street 2:
Mailing Address - City:FOLSOM
Mailing Address - State:CA
Mailing Address - Zip Code:95630-4759
Mailing Address - Country:US
Mailing Address - Phone:916-988-5531
Mailing Address - Fax:
Practice Address - Street 1:193 BLUE RAVINE RD STE 220
Practice Address - Street 2:
Practice Address - City:FOLSOM
Practice Address - State:CA
Practice Address - Zip Code:95630-4759
Practice Address - Country:US
Practice Address - Phone:916-988-5531
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-05
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAPCC4098101YM0800X
101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health