Healthcare Provider Details

I. General information

NPI: 1811276207
Provider Name (Legal Business Name): MRS. LISETH SALES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2011
Last Update Date: 02/28/2023
Certification Date: 02/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

610 14TH ST
MODESTO CA
95354-2505
US

IV. Provider business mailing address

610 14TH ST
MODESTO CA
95354-2505
US

V. Phone/Fax

Practice location:
  • Phone: 209-524-4858
  • Fax:
Mailing address:
  • Phone: 209-214-5804
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number91519
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: