Provider Demographics
NPI:1871738534
Name:LISSA, CLARISA ANDREA (LPT25897)
Entity type:Individual
Prefix:
First Name:CLARISA
Middle Name:ANDREA
Last Name:LISSA
Suffix:
Gender:F
Credentials:LPT25897
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:762 CYPRESS ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIMAS
Mailing Address - State:CA
Mailing Address - Zip Code:91773-3505
Mailing Address - Country:US
Mailing Address - Phone:909-599-1227
Mailing Address - Fax:
Practice Address - Street 1:762 CYPRESS ST
Practice Address - Street 2:
Practice Address - City:SAN DIMAS
Practice Address - State:CA
Practice Address - Zip Code:91773
Practice Address - Country:US
Practice Address - Phone:909-599-1227
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-10
Last Update Date:2018-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT25897167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician