Provider Demographics
NPI:1801877816
Name:HENSON, LISA K (PSYD)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:K
Last Name:HENSON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2212 DUPONT DR
Mailing Address - Street 2:SUITE I
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92612-1525
Mailing Address - Country:US
Mailing Address - Phone:949-481-4221
Mailing Address - Fax:
Practice Address - Street 1:2212 DUPONT DR
Practice Address - Street 2:SUITE I
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92612-1525
Practice Address - Country:US
Practice Address - Phone:949-481-4221
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY18299103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA509109OtherVALUEOPTIONS ID #