Provider Demographics
NPI:1750458212
Name:CLEAVINGER, LISA JANE (MFT)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:JANE
Last Name:CLEAVINGER
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3853 ROSECRANS ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92110-3115
Mailing Address - Country:US
Mailing Address - Phone:619-692-8275
Mailing Address - Fax:619-692-8315
Practice Address - Street 1:3853 ROSECRANS ST.
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110-2670
Practice Address - Country:US
Practice Address - Phone:619-692-8275
Practice Address - Fax:619-692-8315
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2013-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA41634106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA41634OtherMARRIAGE FAMILY THERAPIST