Provider Demographics
NPI:1457803736
Name:OCONNELL, LISA ILENE (MA, MFT)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:ILENE
Last Name:OCONNELL
Suffix:
Gender:F
Credentials:MA, MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4405 W RIVERSIDE DR
Mailing Address - Street 2:SUITE 105
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91505-4072
Mailing Address - Country:US
Mailing Address - Phone:310-281-5573
Mailing Address - Fax:
Practice Address - Street 1:4405 W RIVERSIDE DR
Practice Address - Street 2:SUITE 105
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91505-4072
Practice Address - Country:US
Practice Address - Phone:310-281-5573
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-02
Last Update Date:2016-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT36289106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist