Provider Demographics
NPI:1831260009
Name:LISLE, DOUG J (PHD)
Entity type:Individual
Prefix:
First Name:DOUG
Middle Name:J
Last Name:LISLE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1551 PACIFIC AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95404-3568
Mailing Address - Country:US
Mailing Address - Phone:707-586-5555
Mailing Address - Fax:707-303-4377
Practice Address - Street 1:1551 PACIFIC AVE
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404-3568
Practice Address - Country:US
Practice Address - Phone:707-586-5555
Practice Address - Fax:707-303-4377
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-10
Last Update Date:2008-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY15448103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPL154480Medicare UPIN
CAOPL154480Medicare ID - Type Unspecified