Provider Demographics
NPI:1497985410
Name:LIDDELL, ALYSIA L (PHD)
Entity Type:Individual
Prefix:DR
First Name:ALYSIA
Middle Name:L
Last Name:LIDDELL
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:ALYSIA
Other - Middle Name:
Other - Last Name:LIDDELL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:3941 PARK DR STE 20-359
Mailing Address - Street 2:
Mailing Address - City:EL DORADO HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:95762-4549
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5931 STANLEY AVE STE 1
Practice Address - Street 2:
Practice Address - City:CARMICHAEL
Practice Address - State:CA
Practice Address - Zip Code:95608-3846
Practice Address - Country:US
Practice Address - Phone:916-436-3580
Practice Address - Fax:916-436-3581
Is Sole Proprietor?:No
Enumeration Date:2009-07-24
Last Update Date:2020-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY19996103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical