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General NPI Number Information
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NPI Number | 1447463377
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Entity Type | Individual
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Provider Name | LISA PETRONIS PHD, MA, LMFT
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Gender | Female
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Dates
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Enumeration Date | 05/07/2007
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Last Update Date | 01/05/2016
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Provider Practice Location Address
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Address Line | 9666 BUSINESSPARK AVE STE 101
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City | SAN DIEGO
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State | CA
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Zip | 92131-1646
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Country | US
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Telephone | 619-787-2771
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Fax |
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Provider Business Mailing Address
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Address Line | 9666 BUSINESSPARK AVE STE 101
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City | SAN DIEGO
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State | CA
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Zip | 92131-1646
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Country | US
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Telephone | 858-566-2771
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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 | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | PSY27930
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | 41727
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License Number State | CA
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