Provider Demographics
NPI:1578822219
Name:POWELL, LISA SUSANNE (PSYCHOLOGIST)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:SUSANNE
Last Name:POWELL
Suffix:
Gender:F
Credentials:PSYCHOLOGIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15235 BURBANK BLVD
Mailing Address - Street 2:SUITE B4
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91411-3500
Mailing Address - Country:US
Mailing Address - Phone:818-324-6533
Mailing Address - Fax:
Practice Address - Street 1:15235 BURBANK BLVD
Practice Address - Street 2:SUITE B4
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91411-3500
Practice Address - Country:US
Practice Address - Phone:818-324-6533
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-15
Last Update Date:2012-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY22286103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist