MEDICARE: YI-XIAN LI

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program
2	103TC0700X	Clinical Psychologist	PSY34118	CA

General Provider Information

NPI Number	:	1134659311
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	YI-XIAN LI

Provider Business Mailing Address
First Line	:	PO BOX 2796
Second Line	:
City	:	OLYMPIC VALLEY
State	:	CA
Zip	:	96146-2796
Country	:	US
Telephone Number	:	510-813-9518
Fax Number	:

Provider Business Practice Location Address
First Line	:	288 PACIFIC AVE UNIT 3H
Second Line	:
City	:	SAN FRANCISCO
State	:	CA
Zip	:	94111-1828
Country	:	US
Telephone Number	:	707-340-3158
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/19/2017
Last Update Date	:	04/24/2023

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