Provider Demographics
NPI:1013774884
Name:LISAUSKAS, TRACY ROSE CYNTHIA (LMFT, MA)
Entity Type:Individual
Prefix:
First Name:TRACY ROSE
Middle Name:CYNTHIA
Last Name:LISAUSKAS
Suffix:
Gender:F
Credentials:LMFT, MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33959 DOHENY PARK RD # 1010
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN CAPISTRANO
Mailing Address - State:CA
Mailing Address - Zip Code:92675-4835
Mailing Address - Country:US
Mailing Address - Phone:760-582-2590
Mailing Address - Fax:
Practice Address - Street 1:3504 AVENIDA DEL PRESIDENTE APT 20
Practice Address - Street 2:
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92672-4533
Practice Address - Country:US
Practice Address - Phone:562-261-4103
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-28
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA145077106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist