Provider Demographics
NPI:1972059434
Name:KINNEBREW, LISA MARIE
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:KINNEBREW
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:PLUMMER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BS, MS
Mailing Address - Street 1:730 SUNRISE AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-4549
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1520 EUREKA RD STE 102
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-2849
Practice Address - Country:US
Practice Address - Phone:530-893-0758
Practice Address - Fax:530-893-0502
Is Sole Proprietor?:No
Enumeration Date:2016-08-25
Last Update Date:2023-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172V00000X, 101YA0400X
CAAMFT140797106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No172V00000XOther Service ProvidersCommunity Health Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)