Provider Demographics
NPI:1750142139
Name:LISON, AUSTEN J
Entity type:Individual
Prefix:
First Name:AUSTEN
Middle Name:J
Last Name:LISON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2605 W CURIE AVE APT B
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92704-8352
Mailing Address - Country:US
Mailing Address - Phone:703-431-7839
Mailing Address - Fax:
Practice Address - Street 1:17782 COWAN STE A
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92614-6041
Practice Address - Country:US
Practice Address - Phone:949-722-7118
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-22
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15465101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health