Provider Demographics
NPI:1528328465
Name:FLEDDERMAN, LISA MARIE (IMF)
Entity type:Individual
Prefix:
First Name:LISA MARIE
Middle Name:
Last Name:FLEDDERMAN
Suffix:
Gender:F
Credentials:IMF
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:132 MERCEDES ROAD
Mailing Address - Street 2:
Mailing Address - City:FALLBROOK
Mailing Address - State:CA
Mailing Address - Zip Code:92028
Mailing Address - Country:US
Mailing Address - Phone:760-481-5331
Mailing Address - Fax:760-728-2381
Practice Address - Street 1:1002 E. GRAND
Practice Address - Street 2:
Practice Address - City:ESCONDIDO
Practice Address - State:CA
Practice Address - Zip Code:92025
Practice Address - Country:US
Practice Address - Phone:760-741-2660
Practice Address - Fax:760-741-2647
Is Sole Proprietor?:No
Enumeration Date:2012-05-25
Last Update Date:2012-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA70726106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist