MEDICARE: MRS. LISA MARIE HARRIS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1649001587
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LISA MARIE HARRIS

Provider Business Mailing Address
First Line	:	30125 AGOURA RD STE E
Second Line	:
City	:	AGOURA HILLS
State	:	CA
Zip	:	91301-4337
Country	:	US
Telephone Number	:	805-558-0839
Fax Number	:

Provider Business Practice Location Address
First Line	:	30125 AGOURA RD STE E
Second Line	:
City	:	AGOURA HILLS
State	:	CA
Zip	:	91301-4337
Country	:	US
Telephone Number	:	805-558-0839
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/12/2024
Last Update Date	:	08/12/2024

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