Provider Demographics
NPI:1922139088
Name:CLEMENTE, LISA M (MFT)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:M
Last Name:CLEMENTE
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:MS
Other - First Name:LISA
Other - Middle Name:M
Other - Last Name:NICHOLS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6305 WOODMAN AVE
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91401-2346
Mailing Address - Country:US
Mailing Address - Phone:818-908-4999
Mailing Address - Fax:818-780-0153
Practice Address - Street 1:6305 WOODMAN AVE
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91401-2346
Practice Address - Country:US
Practice Address - Phone:818-908-4999
Practice Address - Fax:818-780-0153
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2017-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC46073106H00000X
CALMFT46073106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist