Provider Demographics
NPI:1851310957
Name:CHARLEBOIS, LISA MARY (LCSW)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARY
Last Name:CHARLEBOIS
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 1:11344 COLOMA RD
Mailing Address - Street 2:SUITE 250
Mailing Address - City:GOLD RIVER
Mailing Address - State:CA
Mailing Address - Zip Code:95670-4457
Mailing Address - Country:US
Mailing Address - Phone:916-552-6122
Mailing Address - Fax:916-852-5838
Practice Address - Street 1:11344 COLOMA RD
Practice Address - Street 2:SUITE 250
Practice Address - City:GOLD RIVER
Practice Address - State:CA
Practice Address - Zip Code:95670-4457
Practice Address - Country:US
Practice Address - Phone:916-552-6122
Practice Address - Fax:916-852-5838
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS 15125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA049887OtherMANAGED HEALTH NETWORK ID
CALCS151251OtherBLUE SHIELD ID #