Healthcare Provider Details

I. General information

NPI: 1053813949
Provider Name (Legal Business Name): LISSA LORRAINE-LYNCH HILL SUDCC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/06/2018
Last Update Date: 06/17/2022
Certification Date: 06/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

484 PLEASANT VALLEY RD. #4
ELDORADO CA
95619-9561
US

IV. Provider business mailing address

484 PLEASANT VALLEY RD SUITE 4
DIAMOND SPRINGS CA
95619-4406
US

V. Phone/Fax

Practice location:
  • Phone: 530-344-7633
  • Fax: 530-497-5202
Mailing address:
  • Phone: 530-344-2831
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number10845
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberR1323840918
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: