Provider Demographics
NPI:1013422906
Name:TODD PETERSEN, LISA JANE
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:JANE
Last Name:TODD PETERSEN
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 1:1417 MANHATTAN BEACH BLVD
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90266-6116
Mailing Address - Country:US
Mailing Address - Phone:310-429-6372
Mailing Address - Fax:
Practice Address - Street 1:515 N SEPULVEDA BLVD
Practice Address - Street 2:
Practice Address - City:MANHATTAN BEACH
Practice Address - State:CA
Practice Address - Zip Code:90266-6748
Practice Address - Country:US
Practice Address - Phone:310-429-6372
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-13
Last Update Date:2017-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103755106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty