Provider Demographics
NPI:1356616999
Name:STORCK, LISEL (MA)
Entity type:Individual
Prefix:
First Name:LISEL
Middle Name:
Last Name:STORCK
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21241 VENTURA BLVD
Mailing Address - Street 2:SUITE 187
Mailing Address - City:WOODLAND HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91364
Mailing Address - Country:US
Mailing Address - Phone:805-551-3408
Mailing Address - Fax:
Practice Address - Street 1:21241 VENTURA BLVD
Practice Address - Street 2:SUITE 187
Practice Address - City:WOODLAND HILLS
Practice Address - State:CA
Practice Address - Zip Code:91364-2108
Practice Address - Country:US
Practice Address - Phone:805-551-3408
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-15
Last Update Date:2012-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALEP 2847103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist