MEDICARE: LISA JANE CLEAVINGER MFT

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	106H00000X	Marriage & Family Therapist	41634	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	41634	OTHER	CA	MARRIAGE FAMILY THERAPIST

General Provider Information

NPI Number	:	1750458212
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA JANE CLEAVINGER MFT

Provider Business Mailing Address
First Line	:	3853 ROSECRANS ST
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92110-3115
Country	:	US
Telephone Number	:	619-692-8275
Fax Number	:	619-692-8315

Provider Business Practice Location Address
First Line	:	3853 ROSECRANS ST.
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92110-2670
Country	:	US
Telephone Number	:	619-692-8275
Fax Number	:	619-692-8315

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

Provider Enumeration Date	:	11/29/2006
Last Update Date	:	02/17/2013

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