Provider Demographics
NPI:1043688997
Name:KIMSEY, LISA (MFTI)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:KIMSEY
Suffix:
Gender:F
Credentials:MFTI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1625 SCHRADER BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90028-6213
Mailing Address - Country:US
Mailing Address - Phone:323-993-2916
Mailing Address - Fax:
Practice Address - Street 1:1625 SCHRADER BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90028-6213
Practice Address - Country:US
Practice Address - Phone:323-993-2916
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-09
Last Update Date:2015-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA87488106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA01536011OtherMEDI-CAL