Basic Information
| Provider Information | |||||||||
| NPI: | 1083987812 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SENETTE-HARRIS | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | RENE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | BA SOCIOLOGY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 43520 DIVISION ST | ||||||||
| Address2: | |||||||||
| City: | LANCASTER | ||||||||
| State: | CA | ||||||||
| PostalCode: | 935354089 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6612664783 | ||||||||
| FaxNumber: | 6612661210 | ||||||||
| Practice Location | |||||||||
| Address1: | 43520 DIVISION ST | ||||||||
| Address2: | |||||||||
| City: | LANCASTER | ||||||||
| State: | CA | ||||||||
| PostalCode: | 935354089 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6612664783 | ||||||||
| FaxNumber: | 6612661210 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/09/2012 | ||||||||
| LastUpdateDate: | 02/15/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225400000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Rehabilitation Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 95-2633765 | 01 | CA | MEDI-CAL | OTHER |