Provider Demographics
NPI:1891337242
Name:BAZA, LISA V
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:V
Last Name:BAZA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1264 N CHALAN CANTON TASI
Mailing Address - Street 2:
Mailing Address - City:YONA
Mailing Address - State:GU
Mailing Address - Zip Code:96915-4644
Mailing Address - Country:US
Mailing Address - Phone:671-777-3764
Mailing Address - Fax:671-477-1077
Practice Address - Street 1:414 W SOLEDAD AVE STE 500Z
Practice Address - Street 2:
Practice Address - City:HAGATNA
Practice Address - State:GU
Practice Address - Zip Code:96910-5066
Practice Address - Country:US
Practice Address - Phone:671-777-3764
Practice Address - Fax:671-477-1077
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-16
Last Update Date:2019-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GULPC-76101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional