Provider Demographics
NPI:1457750143
Name:RICHARDS, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:RICHARDS
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:PO BOX 1346
Mailing Address - Street 2:
Mailing Address - City:IONE
Mailing Address - State:CA
Mailing Address - Zip Code:95640-1346
Mailing Address - Country:US
Mailing Address - Phone:916-704-8374
Mailing Address - Fax:
Practice Address - Street 1:10201 BLUE SKY DR
Practice Address - Street 2:
Practice Address - City:IONE
Practice Address - State:CA
Practice Address - Zip Code:95640-9303
Practice Address - Country:US
Practice Address - Phone:916-704-8374
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-19
Last Update Date:2022-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390200000X
CA32644103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program