Basic Information
| Provider Information | |||||||||
| NPI: | 1184848665 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LYSNE | ||||||||
| FirstName: | ROBIN | ||||||||
| MiddleName: | HEERENS | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.A. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LYSNE | ||||||||
| OtherFirstName: | ROBIN | ||||||||
| OtherMiddleName: | LOPEZ | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.A. | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 335 EAST LAKE AVE | ||||||||
| Address2: | |||||||||
| City: | WATSONVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95076 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8317286445 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 335 E LAKE AVE | ||||||||
| Address2: | |||||||||
| City: | WATSONVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95076 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8317286445 | ||||||||
| FaxNumber: | 8317616011 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2007 | ||||||||
| LastUpdateDate: | 08/09/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 1184848665 | 01 | CA | SUBSTANCE ABUSE COUNSELOR | OTHER |