Basic Information
| Provider Information | |||||||||
| NPI: | 1124202692 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EVERSON | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | DANIELLE | ||||||||
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| Credential: | MFT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 950 N RAMONA BLVD STE 2 | ||||||||
| Address2: | |||||||||
| City: | SAN JACINTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925822571 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9513584625 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 950 N RAMONA BLVD STE 2 | ||||||||
| Address2: | |||||||||
| City: | SAN JACINTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925822571 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9514872674 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/19/2007 | ||||||||
| LastUpdateDate: | 04/13/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | MFC 44486 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.