Provider Demographics
NPI:1639700347
Name:MCINTOSH, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:MCINTOSH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21600 OXNARD ST STE 1800
Mailing Address - Street 2:
Mailing Address - City:WOODLAND HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91367-7807
Mailing Address - Country:US
Mailing Address - Phone:808-345-2345
Mailing Address - Fax:
Practice Address - Street 1:9901 NE 7TH AVE # 116
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98685-4523
Practice Address - Country:US
Practice Address - Phone:360-571-2423
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-31
Last Update Date:2020-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAWDL1SP2GF0SB106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician