Healthcare Provider Details

I. General information

NPI: 1306912902
Provider Name (Legal Business Name): LISA COLLISS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LISA QUIETO

II. Dates (important events)

Enumeration Date: 11/27/2006
Last Update Date: 05/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

51 E CAMPBELL AVE SUITE 103A
CAMPBELL CA
95008-2047
US

IV. Provider business mailing address

51 E CAMPBELL AVE SUITE 103A
CAMPBELL CA
95008-2047
US

V. Phone/Fax

Practice location:
  • Phone: 408-376-4115
  • Fax:
Mailing address:
  • Phone: 408-376-4115
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberACSW18814
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCS24713
License Number StateCA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier4593
Identifier TypeOTHER
Identifier StateCA
Identifier IssuerSANTA CLARA COUNTY ID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: