Healthcare Provider Details

I. General information

NPI: 1851310957
Provider Name (Legal Business Name): LISA MARY CHARLEBOIS L.C.S.W.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11344 COLOMA RD SUITE 250
GOLD RIVER CA
95670-4457
US

IV. Provider business mailing address

11344 COLOMA RD SUITE 250
GOLD RIVER CA
95670-4457
US

V. Phone/Fax

Practice location:
  • Phone: 916-552-6122
  • Fax: 916-852-5838
Mailing address:
  • Phone: 916-552-6122
  • Fax: 916-852-5838

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLCS 15125
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: