Provider Demographics
NPI:1366879967
Name:POLON, LISA SARA (PSYD)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:SARA
Last Name:POLON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3569 ROUND BARN CIR
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-5781
Mailing Address - Country:US
Mailing Address - Phone:707-303-3600
Mailing Address - Fax:
Practice Address - Street 1:3569 ROUND BARN CIR
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-5781
Practice Address - Country:US
Practice Address - Phone:707-303-3600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-27
Last Update Date:2020-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY29914103TC0700X
CAPSB29661103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent