Provider Demographics
NPI:1639585755
Name:REAL, LISA (PSYD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:
Last Name:REAL
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:REAL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:11401 BLOOMFIELD AVE RM 106
Mailing Address - Street 2:
Mailing Address - City:NORWALK
Mailing Address - State:CA
Mailing Address - Zip Code:90650-2015
Mailing Address - Country:US
Mailing Address - Phone:562-521-1152
Mailing Address - Fax:562-651-1201
Practice Address - Street 1:11401 BLOOMFIELD AVE
Practice Address - Street 2:
Practice Address - City:NORWALK
Practice Address - State:CA
Practice Address - Zip Code:90650-2015
Practice Address - Country:US
Practice Address - Phone:562-521-1152
Practice Address - Fax:562-651-1201
Is Sole Proprietor?:No
Enumeration Date:2014-07-09
Last Update Date:2019-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAPSY31150103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program