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: | |||||||||
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| 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 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 167G00000X | PT26009 | CA | Y | Nursing Service Providers | Licensed Psychiatric Technician |
No ID Information.