Healthcare Provider Details

I. General information

NPI: 1548550452
Provider Name (Legal Business Name): LISA RENEE MERCURI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/12/2011
Last Update Date: 04/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000A EMELINE AVE
SANTA CRUZ CA
95060-1900
US

IV. Provider business mailing address

304 3RD ST
SANTA CRUZ CA
95060-5533
US

V. Phone/Fax

Practice location:
  • Phone: 831-425-0112
  • Fax:
Mailing address:
  • Phone: 831-425-0112
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberRI-M1011160935
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: