=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811536618
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LISA PALAC LMFT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/27/2019
-----------------------------------------------------
Last Update Date | 12/28/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 127 HART AVE
-----------------------------------------------------
City | SANTA MONICA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90405-3504
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-825-1677
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 578 WASHINGTON BLVD STE 324
-----------------------------------------------------
City | MARINA DEL REY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90292-5421
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 101981
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------