Provider Demographics
NPI:1578687885
Name:GAVIN-CRUSE, LISA ANNE (MFT)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:ANNE
Last Name:GAVIN-CRUSE
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:GAVIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MFT
Mailing Address - Street 1:1400 S UNION AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93307-4179
Mailing Address - Country:US
Mailing Address - Phone:661-616-7691
Mailing Address - Fax:
Practice Address - Street 1:1412 17TH ST STE 258
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93301-5219
Practice Address - Country:US
Practice Address - Phone:661-616-7691
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2013-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT 34419106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist