MEDICARE: DR. LISSA JOY GEIKEN PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC1900X	Counseling Psychologist	24551	CA

General Provider Information

NPI Number	:	1609181601
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LISSA JOY GEIKEN PH.D.

Provider Business Mailing Address
First Line	:	739 DINGLE LN
Second Line	:
City	:	WOODLAND
State	:	CA
Zip	:	95695-3963
Country	:	US
Telephone Number	:	541-335-1095
Fax Number	:

Provider Business Practice Location Address
First Line	:	1 SHIELDS AVE
Second Line	:	CAPS 219 NORTH HALL
City	:	DAVIS
State	:	CA
Zip	:	95616-5270
Country	:	US
Telephone Number	:	530-752-9923
Fax Number	:	530-752-9923

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/13/2010
Last Update Date	:	09/22/2011

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