Healthcare Provider Details

I. General information

NPI: 1790616142
Provider Name (Legal Business Name): LISA PHAN
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2026
Last Update Date: 05/26/2026
Certification Date: 05/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 FRANKLIN ST
SAN FRANCISCO CA
94102-4414
US

IV. Provider business mailing address

195 E BELLEVUE AVE APT 3
SAN MATEO CA
94401-2349
US

V. Phone/Fax

Practice location:
  • Phone: 415-759-2222
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: