Healthcare Provider Details

I. General information

NPI: 1851642565
Provider Name (Legal Business Name): LISA ANNE WILLMON MFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MISS LISA ANNE LIVINGSTON

II. Dates (important events)

Enumeration Date: 09/21/2012
Last Update Date: 08/10/2024
Certification Date: 08/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

680 E COLORADO BLVD STE 180
PASADENA CA
91101-6144
US

IV. Provider business mailing address

24712 MORNING STAR LN
DANA POINT CA
92629-1826
US

V. Phone/Fax

Practice location:
  • Phone: 646-941-7645
  • Fax: 929-596-7897
Mailing address:
  • Phone: 949-371-6271
  • Fax: 951-684-4538

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number28565
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: