Provider Demographics
NPI:1801438775
Name:LIESTMAN, ERIN DEPUY
Entity type:Individual
Prefix:
First Name:ERIN
Middle Name:DEPUY
Last Name:LIESTMAN
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 1:1664 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92021-5201
Mailing Address - Country:US
Mailing Address - Phone:714-404-8419
Mailing Address - Fax:
Practice Address - Street 1:1664 BROADWAY
Practice Address - Street 2:
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92021-5201
Practice Address - Country:US
Practice Address - Phone:714-404-8419
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-11
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YM0800X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1700919735OtherSAN DIEGO CENTER FOR CHILDREN
CA1760431670OtherCOMMUNITY AND SCHOOL BASED COUNSELING