Provider Demographics
NPI:1720223423
Name:PETRAS, LISA (LMFT)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:PETRAS
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3120 TELEGRAPH AVE STE 11C
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94705-1965
Mailing Address - Country:US
Mailing Address - Phone:415-310-9590
Mailing Address - Fax:
Practice Address - Street 1:3120 TELEGRAPH AVE STE 11C
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94705-1965
Practice Address - Country:US
Practice Address - Phone:415-310-9590
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-09
Last Update Date:2019-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA52581106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist