Provider Demographics
NPI:1912158411
Name:CLEVELAND, LISA
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:CLEVELAND
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7171 BOWLING DR STE 300
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95823-2043
Mailing Address - Country:US
Mailing Address - Phone:279-300-4573
Mailing Address - Fax:510-569-4589
Practice Address - Street 1:7171 BOWLING DR STE 300
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95823-2043
Practice Address - Country:US
Practice Address - Phone:279-300-4573
Practice Address - Fax:510-569-4589
Is Sole Proprietor?:No
Enumeration Date:2008-10-02
Last Update Date:2024-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 104100000X, 171M00000X
CA1081151041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No171M00000XOther Service ProvidersCase Manager/Care Coordinator