Provider Demographics
NPI:1689822082
Name:VICKERY, LYNNESA ESTIVA (MFT)
Entity Type:Individual
Prefix:MRS
First Name:LYNNESA
Middle Name:ESTIVA
Last Name:VICKERY
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2351 CARDINAL LN
Mailing Address - Street 2:ANNEX B
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-3743
Mailing Address - Country:US
Mailing Address - Phone:858-573-2227
Mailing Address - Fax:
Practice Address - Street 1:2351 CARDINAL LN
Practice Address - Street 2:ANNEX B
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-3743
Practice Address - Country:US
Practice Address - Phone:858-573-2227
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-28
Last Update Date:2020-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA63939106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist