Provider Demographics
NPI:1639561657
Name:ILLINGWORTH, LISA PULSIFER (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:PULSIFER
Last Name:ILLINGWORTH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MISS
Other - First Name:LISA
Other - Middle Name:MARIE
Other - Last Name:PULSIFER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:303 NORTH GLENOAKES BLVD.
Mailing Address - Street 2:SUITE #200
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91502-1118
Mailing Address - Country:US
Mailing Address - Phone:818-738-7315
Mailing Address - Fax:818-738-7315
Practice Address - Street 1:303 NORTH GLENOAKES BLVD.
Practice Address - Street 2:SUITE #200
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91502
Practice Address - Country:US
Practice Address - Phone:818-738-7315
Practice Address - Fax:818-738-7315
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-27
Last Update Date:2022-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCSW752771041C0700X
CA752771041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA215NUU2Medicaid