Provider Demographics
NPI:1538982194
Name:FUNDINGSLAND, LISA
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:
Last Name:FUNDINGSLAND
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 1:1277 N MOLLISON AVE UNIT C
Mailing Address - Street 2:
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92021-4769
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1081 CAMINO DEL RIO S
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-3542
Practice Address - Country:US
Practice Address - Phone:619-540-4835
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-04
Last Update Date:2024-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CABACB1209592106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician