Healthcare Provider Details

I. General information

NPI: 1124552955
Provider Name (Legal Business Name): MISS LISSETT CHAVEZ MURILLO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2017
Last Update Date: 05/22/2025
Certification Date: 05/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18350 MOUNT LANGLEY ST STE 200
FOUNTAIN VALLEY CA
92708-6912
US

IV. Provider business mailing address

200 W SANTA ANA BLVD
SANTA ANA CA
92701-4134
US

V. Phone/Fax

Practice location:
  • Phone: 714-378-2620
  • Fax:
Mailing address:
  • Phone: 714-704-5900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number16590
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: