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General NPI Number Information
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NPI Number | 1043483928
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Entity Type | Individual
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Provider Name | MICKEY LIDDEKE
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Gender | Female
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Dates
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Enumeration Date | 04/10/2008
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Last Update Date | 11/20/2009
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Provider Practice Location Address
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Address Line | 24977 WASHINGTON AVE STE. K
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City | MURRIETA
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State | CA
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Zip | 92562-9755
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Country | US
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Telephone | 951-677-1470
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Fax | 951-677-3850
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Provider Business Mailing Address
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Address Line | 2311 WASHINGTON AVE. C110-223
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City | MURRIETA
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State | CA
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Zip | 92564-2564
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Country | US
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Telephone | 951-677-1470
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Fax | 951-677-3850
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | MFC44069
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License Number State | CA
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