Provider Demographics
NPI:1750443420
Name:LAHANA, LISETTE ROSE (LCSW)
Entity Type:Individual
Prefix:
First Name:LISETTE
Middle Name:ROSE
Last Name:LAHANA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:248 3RD ST UNIT 5045
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94607-4375
Mailing Address - Country:US
Mailing Address - Phone:510-915-4795
Mailing Address - Fax:
Practice Address - Street 1:445 BELLEVUE AVE STE 104A
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94610-4923
Practice Address - Country:US
Practice Address - Phone:510-915-4795
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-15
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA236631041C0700X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MALA P21433Medicare ID - Type UnspecifiedMEDICARE B PROVIDER NUM.