Provider Demographics
NPI:1104350677
Name:NELSON, LISA RENAE (LMFT)
Entity type:Individual
Prefix:
First Name:LISA RENAE
Middle Name:
Last Name:NELSON
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 MOUNTAIN HOME RD
Mailing Address - Street 2:
Mailing Address - City:WOODSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:94062-2558
Mailing Address - Country:US
Mailing Address - Phone:650-283-2839
Mailing Address - Fax:
Practice Address - Street 1:1200 MOUNTAIN HOME RD
Practice Address - Street 2:
Practice Address - City:WOODSIDE
Practice Address - State:CA
Practice Address - Zip Code:94062-2558
Practice Address - Country:US
Practice Address - Phone:650-283-2839
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-12
Last Update Date:2017-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 43285106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist