Healthcare Provider Details

I. General information

NPI: 1174072060
Provider Name (Legal Business Name): LISA WOLFE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2016
Last Update Date: 07/08/2021
Certification Date: 07/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1722 S LEWIS RD
CAMARILLO CA
93012-8520
US

IV. Provider business mailing address

2615 S MILLER ST SUITE 106
SANTA MARIA CA
93455-1775
US

V. Phone/Fax

Practice location:
  • Phone: 805-366-4040
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number99118
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: