Healthcare Provider Details

I. General information

NPI: 1346880473
Provider Name (Legal Business Name): LISA M. BLACKMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/07/2020
Last Update Date: 07/02/2026
Certification Date: 07/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14071 PEYTON DR # 15223
CHINO HILLS CA
91709-7241
US

IV. Provider business mailing address

16628 BERRYHEATH CT
CHINO HILLS CA
91709-3964
US

V. Phone/Fax

Practice location:
  • Phone: 909-239-2674
  • Fax:
Mailing address:
  • Phone: 909-239-2674
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberLMFT161430
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: