Healthcare Provider Details

I. General information

NPI: 1487149407
Provider Name (Legal Business Name): LA TISHA LYNN SAN PEDRO-LINTAG LMFT 133780
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/22/2018
Last Update Date: 07/22/2022
Certification Date: 07/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3431 SLY PARK RD
POLLOCK PINES CA
95726-9520
US

IV. Provider business mailing address

PO BOX 445
POLLOCK PINES CA
95726-0445
US

V. Phone/Fax

Practice location:
  • Phone: 209-975-7919
  • Fax:
Mailing address:
  • Phone: 916-583-4426
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: