=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497985410
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ALYSIA L LIDDELL PH.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/24/2009
-----------------------------------------------------
Last Update Date | 02/06/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5931 STANLEY AVE STE 1
-----------------------------------------------------
City | CARMICHAEL
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95608-3846
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-436-3580
-----------------------------------------------------
Fax | 916-436-3581
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3941 PARK DR STE 20-359
-----------------------------------------------------
City | EL DORADO HILLS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95762-4549
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | PSY19996
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------