Healthcare Provider Details

I. General information

NPI: 1669502829
Provider Name (Legal Business Name): LISA ANNE LUCIUS MA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/06/2007
Last Update Date: 12/17/2024
Certification Date: 12/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4144 56TH ST N
KENNETH CITY FL
33709-5416
US

IV. Provider business mailing address

4144 56TH ST N APT 811
KENNETH CITY FL
33709-5447
US

V. Phone/Fax

Practice location:
  • Phone: 323-680-8497
  • Fax:
Mailing address:
  • Phone: 323-680-8497
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number46743
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: