Provider Demographics
NPI:1053697250
Name:HERRMANN, LISA KAY
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:KAY
Last Name:HERRMANN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 E MAIN ST STE 117
Mailing Address - Street 2:
Mailing Address - City:BARSTOW
Mailing Address - State:CA
Mailing Address - Zip Code:92311-2365
Mailing Address - Country:US
Mailing Address - Phone:760-255-1496
Mailing Address - Fax:760-255-2542
Practice Address - Street 1:222 E MAIN ST. SUITE 117
Practice Address - Street 2:
Practice Address - City:BARSTOW
Practice Address - State:CA
Practice Address - Zip Code:92311
Practice Address - Country:US
Practice Address - Phone:760-255-1496
Practice Address - Fax:760-255-2542
Is Sole Proprietor?:No
Enumeration Date:2011-11-01
Last Update Date:2024-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
CA119750106H00000X
CA147009106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor