Basic Information
| Provider Information | |||||||||
| NPI: | 1760719876 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WARREN | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MFT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CROUCH | ||||||||
| OtherFirstName: | LISA | ||||||||
| OtherMiddleName: | M | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 528 EAST CALAVERAS ST | ||||||||
| Address2: | |||||||||
| City: | ALTADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 91001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3232520546 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 36 S KINNELOA AVE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911073853 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6268443033 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/10/2009 | ||||||||
| LastUpdateDate: | 05/31/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | MFC53629 | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.