Provider Demographics
NPI:1720166911
Name:HILDRETH, LISA M
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:HILDRETH
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 1:6454 KINGLET WAY
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92011-2700
Mailing Address - Country:US
Mailing Address - Phone:760-420-1992
Mailing Address - Fax:
Practice Address - Street 1:2910 JEFFERSON ST
Practice Address - Street 2:SUITE 201
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92008-2356
Practice Address - Country:US
Practice Address - Phone:760-420-1992
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2012-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA52168106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist