Provider Demographics
NPI:1902371016
Name:DO, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:DO
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 1:11336 LOWER AZUSA RD
Mailing Address - Street 2:
Mailing Address - City:EL MONTE
Mailing Address - State:CA
Mailing Address - Zip Code:91732-1329
Mailing Address - Country:US
Mailing Address - Phone:626-478-7812
Mailing Address - Fax:
Practice Address - Street 1:2750 E WASHINGTON BLVD STE 230
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91107-1449
Practice Address - Country:US
Practice Address - Phone:626-296-8900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-04
Last Update Date:2020-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390200000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician