Provider Demographics
NPI:1194874495
Name:SELIZ, LISA
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:
Last Name:SELIZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1009 ASHPORT ST
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91768-2323
Mailing Address - Country:US
Mailing Address - Phone:909-561-8899
Mailing Address - Fax:
Practice Address - Street 1:125 W F ST
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91762-3262
Practice Address - Country:US
Practice Address - Phone:909-986-4550
Practice Address - Fax:909-986-4506
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)