=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497152995
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LISA MAZNIO LPC, CCM, QMHP, BCC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/26/2014
-----------------------------------------------------
Last Update Date | 07/06/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1400 N MARTEL AVE APT 202
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90046
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-495-1159
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1400 N MARTEL AVE APT 202
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90046-4276
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-495-1159
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 6401002419
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------