Provider Demographics
NPI:1982210811
Name:ALLEN, LISA (AMFT, APCC)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:ALLEN
Suffix:
Gender:F
Credentials:AMFT, APCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:352 DELAWARE ST
Mailing Address - Street 2:
Mailing Address - City:IMPERIAL BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:91932-1421
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2339 11TH ST
Practice Address - Street 2:
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024-6604
Practice Address - Country:US
Practice Address - Phone:760-456-7462
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-16
Last Update Date:2020-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7995101YM0800X
CA120958106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health