Provider Demographics
NPI:1598106809
Name:LISSNER, NICOLAI JOSEPH
Entity Type:Individual
Prefix:
First Name:NICOLAI
Middle Name:JOSEPH
Last Name:LISSNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4000 W METROPOLITAN DR STE 120
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-3504
Mailing Address - Country:US
Mailing Address - Phone:714-972-3700
Mailing Address - Fax:
Practice Address - Street 1:4000 W METROPOLITAN DR STE 120
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-3504
Practice Address - Country:US
Practice Address - Phone:714-972-3700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-15
Last Update Date:2022-01-27
Deactivation Date:2020-11-10
Deactivation Code:
Reactivation Date:2020-12-02
Provider Licenses
StateLicense IDTaxonomies
CA1064971041C0700X
CA689021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical