Provider Demographics
NPI:1891907432
Name:VILDOSOLA, LISA ANN
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:ANN
Last Name:VILDOSOLA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:802 W COLTON AVE STE C
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92374-2905
Mailing Address - Country:US
Mailing Address - Phone:909-335-2989
Mailing Address - Fax:909-335-1701
Practice Address - Street 1:802 W COLTON AVE
Practice Address - Street 2:SUITE C
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92374-2905
Practice Address - Country:US
Practice Address - Phone:909-335-2989
Practice Address - Fax:909-335-1701
Is Sole Proprietor?:No
Enumeration Date:2007-05-04
Last Update Date:2011-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA112248101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)