Provider Demographics
NPI:1043483928
Name:LIDDEKE, MICKEY
Entity type:Individual
Prefix:
First Name:MICKEY
Middle Name:
Last Name:LIDDEKE
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 1:2311 WASHINGTON AVE.
Mailing Address - Street 2:C110-223
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92564-2564
Mailing Address - Country:US
Mailing Address - Phone:951-677-1470
Mailing Address - Fax:951-677-3850
Practice Address - Street 1:24977 WASHINGTON AVE
Practice Address - Street 2:STE. K
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92562-9755
Practice Address - Country:US
Practice Address - Phone:951-677-1470
Practice Address - Fax:951-677-3850
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-10
Last Update Date:2009-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC44069106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist