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NPI Code Detail

MEDICARE: LISA MARIE DOUGLAS

MEDICARE: LISA MARIE DOUGLAS
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
1106H00000XMarriage & Family TherapistMFI71212CA

General Provider Information

NPI Number : 1972943124
Entity Type Code : Individual
Provider Name (Legal Business Name) : LISA MARIE DOUGLAS
Provider Business Mailing Address
First Line : 2002 VANDERBILT LN APT C
Second Line :
City : REDONDO BEACH
State : CA
Zip : 90278-3062
Country : US
Telephone Number : 408-646-7632
Fax Number :
Provider Business Practice Location Address
First Line : 2002 VANDERBILT LN APT C
Second Line :
City : REDONDO BEACH
State : CA
Zip : 90278-3062
Country : US
Telephone Number : 408-646-7632
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/02/2013
Last Update Date : 07/02/2013

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