Provider Demographics
NPI:1851642565
Name:WILLMON, LISA ANNE (MFT)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:ANNE
Last Name:WILLMON
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:MISS
Other - First Name:LISA
Other - Middle Name:ANNE
Other - Last Name:LIVINGSTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3590 CENTRAL AVE
Mailing Address - Street 2:SUITE 208
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506-2708
Mailing Address - Country:US
Mailing Address - Phone:951-320-1390
Mailing Address - Fax:951-684-4538
Practice Address - Street 1:3590 CENTRAL AVE
Practice Address - Street 2:SUITE 208
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-2708
Practice Address - Country:US
Practice Address - Phone:951-320-1390
Practice Address - Fax:951-684-4538
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-21
Last Update Date:2012-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA28565106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist