Basic Information
| Provider Information | |||||||||
| NPI: | 1083262505 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HARRIS | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | MONIQUE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 611 E BELMONT AVE | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937011502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5592373420 | ||||||||
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| Practice Location | |||||||||
| Address1: | 611 BELMONT | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 93728 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5592373420 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/28/2019 | ||||||||
| LastUpdateDate: | 08/31/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YA0400X | CA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 1083262505 | 01 | CA | MEDICAL | OTHER | 3512 | 01 | SECURITY CODE | OTHER |