=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396073052
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LISA P DOW PH.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/18/2009
-----------------------------------------------------
Last Update Date | 11/30/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9353 IMPERIAL HWY
-----------------------------------------------------
City | DOWNEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90242-2812
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-657-4019
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3075 NIGHTWIND CIR
-----------------------------------------------------
City | CORONA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92882-6061
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-279-3375
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | PSY16520
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------