Healthcare Provider Details

I. General information

NPI: 1548478415
Provider Name (Legal Business Name): LISA MOUA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1031 25TH ST
SAN DIEGO CA
92102-2102
US

IV. Provider business mailing address

10714 HOLLY MEADOWS DR UNIT C
SANTEE CA
92071-5432
US

V. Phone/Fax

Practice location:
  • Phone: 619-232-6454
  • Fax:
Mailing address:
  • Phone: 619-749-1150
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225C00000X
TaxonomyRehabilitation Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: