Healthcare Provider Details

I. General information

NPI: 1326376617
Provider Name (Legal Business Name): LISA ANN HARRIS MFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LISA ANN VANDENRAADT MFT

II. Dates (important events)

Enumeration Date: 11/24/2009
Last Update Date: 04/25/2023
Certification Date: 04/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4075 TWINING ST
JURUPA VALLEY CA
92509-6758
US

IV. Provider business mailing address

11179 HAMAL AVE.
JURUPA VALLEY CA
91752
US

V. Phone/Fax

Practice location:
  • Phone: 951-990-2497
  • Fax:
Mailing address:
  • Phone: 951-990-2497
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFT 62190
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number105746
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: