Provider Demographics
NPI:1760534853
Name:LILJEQUIST, TRACY (MFT)
Entity Type:Individual
Prefix:MS
First Name:TRACY
Middle Name:
Last Name:LILJEQUIST
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 1:12636 SARSAPARILLA ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92129-3735
Mailing Address - Country:US
Mailing Address - Phone:858-354-5514
Mailing Address - Fax:
Practice Address - Street 1:2345 E 8TH ST
Practice Address - Street 2:SUITE 103
Practice Address - City:NATIONAL CITY
Practice Address - State:CA
Practice Address - Zip Code:91950-2800
Practice Address - Country:US
Practice Address - Phone:858-354-5514
Practice Address - Fax:619-267-9307
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2008-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC42206106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist