Provider Demographics
NPI:1659953230
Name:LIZAMA, XIMENA ANDREA
Entity Type:Individual
Prefix:
First Name:XIMENA
Middle Name:ANDREA
Last Name:LIZAMA
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 1:1524 E OAK AVE
Mailing Address - Street 2:
Mailing Address - City:LOMPOC
Mailing Address - State:CA
Mailing Address - Zip Code:93436-3711
Mailing Address - Country:US
Mailing Address - Phone:786-454-5946
Mailing Address - Fax:
Practice Address - Street 1:101 S B ST
Practice Address - Street 2:
Practice Address - City:LOMPOC
Practice Address - State:CA
Practice Address - Zip Code:93436-6933
Practice Address - Country:US
Practice Address - Phone:805-450-7351
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-23
Last Update Date:2021-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAPCC9144101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health