Provider Demographics
NPI:1447463377
Name:PETRONIS, LISA (PHD, MA, LMFT)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:
Last Name:PETRONIS
Suffix:
Gender:F
Credentials:PHD, MA, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9666 BUSINESSPARK AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92131-1646
Mailing Address - Country:US
Mailing Address - Phone:858-566-2771
Mailing Address - Fax:
Practice Address - Street 1:9666 BUSINESSPARK AVE STE 101
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92131-1646
Practice Address - Country:US
Practice Address - Phone:619-787-2771
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-07
Last Update Date:2016-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY27930103TC0700X
CA41727106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist