Provider Demographics
NPI:1316325459
Name:LIZARRAGA, OMAR
Entity type:Individual
Prefix:
First Name:OMAR
Middle Name:
Last Name:LIZARRAGA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9808 SAN MIGUEL AVE APT A
Mailing Address - Street 2:
Mailing Address - City:SOUTH GATE
Mailing Address - State:CA
Mailing Address - Zip Code:90280-4824
Mailing Address - Country:US
Mailing Address - Phone:323-867-0809
Mailing Address - Fax:626-577-4250
Practice Address - Street 1:1450 N LAKE AVE FL 2
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91104-2301
Practice Address - Country:US
Practice Address - Phone:626-564-4240
Practice Address - Fax:626-577-4250
Is Sole Proprietor?:No
Enumeration Date:2015-05-08
Last Update Date:2015-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)