Healthcare Provider Details

I. General information

NPI: 1750142139
Provider Name (Legal Business Name): AUSTEN J LISON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/22/2024
Last Update Date: 01/22/2024
Certification Date: 01/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17782 COWAN STE A
IRVINE CA
92614-6041
US

IV. Provider business mailing address

2605 W CURIE AVE APT B
SANTA ANA CA
92704-8352
US

V. Phone/Fax

Practice location:
  • Phone: 949-722-7118
  • Fax:
Mailing address:
  • Phone: 703-431-7839
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number15465
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: