Provider Demographics
NPI:1629205349
Name:BERMEO, LISA RENEE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:RENEE
Last Name:BERMEO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 BAKER CT
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94952-5520
Mailing Address - Country:US
Mailing Address - Phone:707-228-5368
Mailing Address - Fax:707-773-1766
Practice Address - Street 1:99 MONTECILLO RD
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94903-3308
Practice Address - Country:US
Practice Address - Phone:415-444-4251
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-20
Last Update Date:2009-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA250741041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical