Provider Demographics
NPI:1124827829
Name:OFFUTT, LISA MONIQUE
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:MONIQUE
Last Name:OFFUTT
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15067 RAMONA RD
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92307-3425
Mailing Address - Country:US
Mailing Address - Phone:909-647-8519
Mailing Address - Fax:
Practice Address - Street 1:612 S MYRTLE AVE STE 100
Practice Address - Street 2:
Practice Address - City:MONROVIA
Practice Address - State:CA
Practice Address - Zip Code:91016-3406
Practice Address - Country:US
Practice Address - Phone:714-791-4693
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-13
Last Update Date:2025-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician