Healthcare Provider Details

I. General information

NPI: 1396599031
Provider Name (Legal Business Name): LISSA ZOLTAK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/17/2024
Last Update Date: 08/13/2025
Certification Date: 08/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2625 TOWNSGATE RD STE 102
WESTLAKE VILLAGE CA
91361-5726
US

IV. Provider business mailing address

12950 RANCHO VISTA CT
SANTA ROSA VALLEY CA
93012-9301
US

V. Phone/Fax

Practice location:
  • Phone: 805-413-3009
  • Fax:
Mailing address:
  • Phone: 805-506-3327
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: