Provider Demographics
NPI:1992377048
Name:MAITLAND, LISA MARIE
Entity Type:Individual
Prefix:
First Name:LISA MARIE
Middle Name:
Last Name:MAITLAND
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 1:4120 DALE RD.
Mailing Address - Street 2:SUITE J-8 #102
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95356
Mailing Address - Country:US
Mailing Address - Phone:209-412-3758
Mailing Address - Fax:
Practice Address - Street 1:4120 DALE RD.
Practice Address - Street 2:SUITE J-8 #102
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95356
Practice Address - Country:US
Practice Address - Phone:209-412-3758
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-16
Last Update Date:2021-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA706321041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty