Provider Demographics
NPI:1487162079
Name:ROSALES, LISA KATHLEEN (MA)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:KATHLEEN
Last Name:ROSALES
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:309 E MOUNTAIN VIEW ST STE 100
Mailing Address - Street 2:
Mailing Address - City:BARSTOW
Mailing Address - State:CA
Mailing Address - Zip Code:92311-2814
Mailing Address - Country:US
Mailing Address - Phone:760-256-7279
Mailing Address - Fax:
Practice Address - Street 1:10755 APPLE VALLEY RD
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92308-3684
Practice Address - Country:US
Practice Address - Phone:760-247-9840
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-17
Last Update Date:2019-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA4113101YM0800X
CA100326106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA100326OtherBEHAVIORAL HEALTH