Provider Demographics
NPI:1134158645
Name:LARSEN, LISA SONIN (PSYD)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:SONIN
Last Name:LARSEN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43706 SENTRY LN
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93536-5864
Mailing Address - Country:US
Mailing Address - Phone:661-233-6771
Mailing Address - Fax:661-206-9340
Practice Address - Street 1:43706 SENTRY LN
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93536-5864
Practice Address - Country:US
Practice Address - Phone:661-233-6771
Practice Address - Fax:661-206-9340
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2010-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY19046103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACB809AOtherPTAN
CACB809AOtherPTAN
CAQ09494Medicare UPIN