Provider Demographics
NPI:1457488322
Name:CICCARELLI, LISA MICHELE (MFT, MS)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:MICHELE
Last Name:CICCARELLI
Suffix:
Gender:F
Credentials:MFT, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1027 CRIMSON DR
Mailing Address - Street 2:
Mailing Address - City:SAN MARCOS
Mailing Address - State:CA
Mailing Address - Zip Code:92069-1193
Mailing Address - Country:US
Mailing Address - Phone:760-510-1744
Mailing Address - Fax:760-510-1744
Practice Address - Street 1:135 E 3RD AVE
Practice Address - Street 2:SUITE B
Practice Address - City:ESCONDIDO
Practice Address - State:CA
Practice Address - Zip Code:92025-4252
Practice Address - Country:US
Practice Address - Phone:760-737-9694
Practice Address - Fax:760-747-5474
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 31473106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist