Healthcare Provider Details

I. General information

NPI: 1518223759
Provider Name (Legal Business Name): LISA RENEE CASEY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/02/2012
Last Update Date: 04/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

151 KALMUS DR STE K3
COSTA MESA CA
92626-5975
US

IV. Provider business mailing address

151 KALMUS DR STE K3
COSTA MESA CA
92626-5975
US

V. Phone/Fax

Practice location:
  • Phone: 714-384-3870
  • Fax:
Mailing address:
  • Phone: 714-384-3870
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number395198
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: