Provider Demographics
NPI:1942087176
Name:RISNER, DEMETRA
Entity Type:Individual
Prefix:
First Name:DEMETRA
Middle Name:
Last Name:RISNER
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 1:600 ALHAMBRA WAY APT 3
Mailing Address - Street 2:
Mailing Address - City:MARTINEZ
Mailing Address - State:CA
Mailing Address - Zip Code:94553-3946
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:51 MARINA BLVD STE D
Practice Address - Street 2:
Practice Address - City:PITTSBURG
Practice Address - State:CA
Practice Address - Zip Code:94565-2068
Practice Address - Country:US
Practice Address - Phone:510-273-4700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-11
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA129996106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist