Provider Demographics
NPI:1306912902
Name:COLLISS, LISA (LCSW)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:COLLISS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:QUIETO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:51 E CAMPBELL AVE
Mailing Address - Street 2:SUITE 103A
Mailing Address - City:CAMPBELL
Mailing Address - State:CA
Mailing Address - Zip Code:95008-2047
Mailing Address - Country:US
Mailing Address - Phone:408-376-4115
Mailing Address - Fax:
Practice Address - Street 1:51 E CAMPBELL AVE
Practice Address - Street 2:SUITE 103A
Practice Address - City:CAMPBELL
Practice Address - State:CA
Practice Address - Zip Code:95008-2047
Practice Address - Country:US
Practice Address - Phone:408-376-4115
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-27
Last Update Date:2012-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAACSW188141041C0700X
CALCS247131041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA4593OtherSANTA CLARA COUNTY ID