Provider Demographics
NPI:1194942771
Name:MINK, LISA MICHELLE (MS)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:MICHELLE
Last Name:MINK
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4227 E MAIN ST STE 200
Mailing Address - Street 2:
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93003-8216
Mailing Address - Country:US
Mailing Address - Phone:805-276-8605
Mailing Address - Fax:
Practice Address - Street 1:4227 E MAIN ST STE 200
Practice Address - Street 2:
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003-8216
Practice Address - Country:US
Practice Address - Phone:805-276-8605
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2008-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF 40548390200000X
CAMFC# 45927106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program