Basic Information
Provider Information | |||||||||
NPI: | 1811288178 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HALVERSON | ||||||||
FirstName: | LISA | ||||||||
MiddleName: | LYNETTE | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | LPT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | LITTLES | ||||||||
OtherFirstName: | LISA | ||||||||
OtherMiddleName: | LYNETTE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 368 FELL ST | ||||||||
Address2: |   | ||||||||
City: | SAN FRANCISCO | ||||||||
State: | CA | ||||||||
PostalCode: | 941025144 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4158610828 | ||||||||
FaxNumber: | 4158610257 | ||||||||
Practice Location | |||||||||
Address1: | 52 DORE ST | ||||||||
Address2: |   | ||||||||
City: | SAN FRANCISCO | ||||||||
State: | CA | ||||||||
PostalCode: | 941033828 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4155533100 | ||||||||
FaxNumber: | 4158610257 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/21/2011 | ||||||||
LastUpdateDate: | 04/21/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 167G00000X | PT26009 | CA | Y |   | Nursing Service Providers | Licensed Psychiatric Technician |   |
No ID Information.