Provider Demographics
NPI:1649398918
Name:SPIVACK, LISA
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:
Last Name:SPIVACK
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 1:16 LOCUST AVE
Mailing Address - Street 2:
Mailing Address - City:MILL VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94941-2806
Mailing Address - Country:US
Mailing Address - Phone:415-378-2016
Mailing Address - Fax:415-378-2016
Practice Address - Street 1:16 LOCUST AVE
Practice Address - Street 2:
Practice Address - City:MILL VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94941-2806
Practice Address - Country:US
Practice Address - Phone:415-378-2016
Practice Address - Fax:415-378-2016
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2010-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC #45618106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist