Healthcare Provider Details

I. General information

NPI: 1508155367
Provider Name (Legal Business Name): LISA MARIE KREKLER LCSW, DSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/01/2011
Last Update Date: 08/24/2021
Certification Date: 07/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3017 TELEGRAPH AVE STE 210
BERKELEY CA
94705
US

IV. Provider business mailing address

960 POSTAL WAY UNIT 2996
VISTA CA
92085-7121
US

V. Phone/Fax

Practice location:
  • Phone: 760-237-8112
  • Fax: 760-330-2108
Mailing address:
  • Phone: 760-237-8112
  • Fax: 760-330-2108

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCS 25734
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: