Provider Demographics
NPI:1952445454
Name:LARIMER BURTIS, LISA (LMFT)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:LARIMER BURTIS
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 653
Mailing Address - Street 2:
Mailing Address - City:MENDOCINO
Mailing Address - State:CA
Mailing Address - Zip Code:95460-0653
Mailing Address - Country:US
Mailing Address - Phone:707-972-2261
Mailing Address - Fax:707-937-1876
Practice Address - Street 1:347 CYPRESS ST STE A
Practice Address - Street 2:
Practice Address - City:FORT BRAGG
Practice Address - State:CA
Practice Address - Zip Code:95437-5458
Practice Address - Country:US
Practice Address - Phone:707-972-2261
Practice Address - Fax:707-937-1876
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-16
Last Update Date:2022-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT49997106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1952445454Medicaid