Provider Demographics
NPI:1568772739
Name:LIFRAK, LISA (MFT, MA)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:LIFRAK
Suffix:
Gender:F
Credentials:MFT, MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8054 VALENCIA ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:APTOS
Mailing Address - State:CA
Mailing Address - Zip Code:95003-3984
Mailing Address - Country:US
Mailing Address - Phone:831-419-3317
Mailing Address - Fax:
Practice Address - Street 1:8054 VALENCIA ST
Practice Address - Street 2:SUITE A
Practice Address - City:APTOS
Practice Address - State:CA
Practice Address - Zip Code:95003-3984
Practice Address - Country:US
Practice Address - Phone:831-419-3317
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-20
Last Update Date:2010-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 31613106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA066719OtherMHN - MANAGED HEALTH NETWORK, INC.