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General NPI Number Information
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NPI Number | 1013774884
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Entity Type | Individual
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Provider Name | TRACY ROSE CYNTHIA LISAUSKAS LMFT, MA
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Gender | Female
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Dates
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Enumeration Date | 02/28/2024
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Last Update Date | 02/28/2024
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Provider Practice Location Address
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Address Line | 3504 AVENIDA DEL PRESIDENTE APT 20
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City | SAN CLEMENTE
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State | CA
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Zip | 92672-4533
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Country | US
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Telephone | 562-261-4103
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Fax |
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Provider Business Mailing Address
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Address Line | 33959 DOHENY PARK RD # 1010
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City | SAN JUAN CAPISTRANO
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State | CA
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Zip | 92675-4835
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Country | US
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Telephone | 760-582-2590
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | 145077
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License Number State | CA
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