Provider Demographics
NPI:1548724222
Name:GINSBURG, LISA SETIADI
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:SETIADI
Last Name:GINSBURG
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 1:5431 VILLAGE GRN
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90016-5106
Mailing Address - Country:US
Mailing Address - Phone:323-627-9040
Mailing Address - Fax:
Practice Address - Street 1:5431 VILLAGE GRN
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90016-5106
Practice Address - Country:US
Practice Address - Phone:323-872-6330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-26
Last Update Date:2019-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-18-33616103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1-18-33616OtherBCBA