Provider Demographics
NPI:1619141082
Name:MIN, LISA N (MS, MFT)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:N
Last Name:MIN
Suffix:
Gender:F
Credentials:MS, MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:SOCIAL SERVICES UNIVERSITY HEALTH SERVICES
Mailing Address - Street 2:2222 BANCROFT WAY
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94720-0001
Mailing Address - Country:US
Mailing Address - Phone:510-642-6074
Mailing Address - Fax:510-643-0211
Practice Address - Street 1:SOCIAL SERVICES UNIVERSITY HEALTH SERVICES
Practice Address - Street 2:2222 BANCROFT WAY
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94720-0001
Practice Address - Country:US
Practice Address - Phone:510-642-6074
Practice Address - Fax:510-643-0211
Is Sole Proprietor?:No
Enumeration Date:2008-04-16
Last Update Date:2008-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC40240106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist