Healthcare Provider Details

I. General information

NPI: 1487162079
Provider Name (Legal Business Name): LISA KATHLEEN ROSALES MA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/17/2018
Last Update Date: 04/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10755 APPLE VALLEY RD
APPLE VALLEY CA
92308-3684
US

IV. Provider business mailing address

309 E MOUNTAIN VIEW ST STE 100
BARSTOW CA
92311-2814
US

V. Phone/Fax

Practice location:
  • Phone: 760-247-9840
  • Fax:
Mailing address:
  • Phone: 760-256-7279
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number4113
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number100326
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: