Provider Demographics
NPI:1083926406
Name:THIEL, LISA M (LCSW)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:THIEL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:474 W VERMONT AVE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:ESCONDIDO
Mailing Address - State:CA
Mailing Address - Zip Code:92025-6584
Mailing Address - Country:US
Mailing Address - Phone:619-683-3100
Mailing Address - Fax:
Practice Address - Street 1:474 W VERMONT AVE
Practice Address - Street 2:SUITE 104
Practice Address - City:ESCONDIDO
Practice Address - State:CA
Practice Address - Zip Code:92025-6584
Practice Address - Country:US
Practice Address - Phone:619-683-3100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-14
Last Update Date:2016-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW65795101YM0800X
101Y00000X, 104100000X
CA710001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No104100000XBehavioral Health & Social Service ProvidersSocial Worker