Provider Demographics
NPI:1558496844
Name:GRANT, LISA CAMILLE (MFT)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:CAMILLE
Last Name:GRANT
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 S MCDONNELL AVE
Mailing Address - Street 2:
Mailing Address - City:COMMERCE
Mailing Address - State:CA
Mailing Address - Zip Code:90040-5623
Mailing Address - Country:US
Mailing Address - Phone:323-981-4307
Mailing Address - Fax:
Practice Address - Street 1:1500 S MCDONNELL AVE
Practice Address - Street 2:
Practice Address - City:COMMERCE
Practice Address - State:CA
Practice Address - Zip Code:90040-5623
Practice Address - Country:US
Practice Address - Phone:323-981-4307
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-23
Last Update Date:2023-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA50052106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist