Provider Demographics
NPI:1811366065
Name:IREY, LISA ANN (MS, LMFT, 128538)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:ANN
Last Name:IREY
Suffix:
Gender:F
Credentials:MS, LMFT, 128538
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5186 BENITO ST UNIT 122
Mailing Address - Street 2:
Mailing Address - City:MONTCLAIR
Mailing Address - State:CA
Mailing Address - Zip Code:91763-8105
Mailing Address - Country:US
Mailing Address - Phone:909-489-2786
Mailing Address - Fax:
Practice Address - Street 1:3200 E GUASTI RD STE 100
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91761-8661
Practice Address - Country:US
Practice Address - Phone:909-527-5969
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-17
Last Update Date:2022-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA122851106H00000X
CA128538106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA128538OtherBOARD OF BEHAVIORAL SCIENCES
CA1811366065Medicaid