Provider Demographics
NPI:1952431793
Name:BENNETT, LISAH NICHOLE (MS MFT)
Entity Type:Individual
Prefix:
First Name:LISAH
Middle Name:NICHOLE
Last Name:BENNETT
Suffix:
Gender:F
Credentials:MS MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 S. FAIR OAKS AVE. STE. 300
Mailing Address - Street 2:
Mailing Address - City:S. PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91030
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:625 S. FAIR OAKS BLVD #300
Practice Address - Street 2:
Practice Address - City:SOUTH PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91030
Practice Address - Country:US
Practice Address - Phone:626-831-2509
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2007-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF 46200225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner