Healthcare Provider Details

I. General information

NPI: 1497258370
Provider Name (Legal Business Name): LISA RAE REPP B.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/16/2018
Last Update Date: 08/18/2022
Certification Date: 08/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12432 BELLFLOWER BLVD
DOWNEY CA
90242-2806
US

IV. Provider business mailing address

1333 S MAYFLOWER AVE STE 220
MONROVIA CA
91016-5239
US

V. Phone/Fax

Practice location:
  • Phone: 855-295-3276
  • Fax: 800-819-7806
Mailing address:
  • Phone: 818-241-6780
  • Fax: 8-197-8068

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-21-51239
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: