=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700603347
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LISA CABRAL
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/24/2024
-----------------------------------------------------
Last Update Date | 09/24/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4060 CHESTNUT ST
-----------------------------------------------------
City | RIVERSIDE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92501-3537
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-470-1456
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11268 WINGATE DR
-----------------------------------------------------
City | ALTA LOMA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91701-9119
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-202-2285
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------