Healthcare Provider Details

I. General information

NPI: 1841788320
Provider Name (Legal Business Name): LISA MICHELLE HARRISON DPM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/30/2018
Last Update Date: 08/16/2021
Certification Date: 08/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3000 COLBY ST STE 104
BERKELEY CA
94705-2090
US

IV. Provider business mailing address

3000 COLBY ST STE 104
BERKELEY CA
94705-2090
US

V. Phone/Fax

Practice location:
  • Phone: 510-849-3800
  • Fax: 510-849-3810
Mailing address:
  • Phone: 510-849-3800
  • Fax: 510-849-3810

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberE5798
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: