MEDICARE: DR. LYDIA VON IMM PHD

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	103T00000X	Psychologist	PSY12267	CA

General Provider Information

NPI Number	:	1326168501
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LYDIA VON IMM PHD

Provider Business Mailing Address
First Line	:	PO BOX 2421
Second Line	:
City	:	CARLSBAD
State	:	CA
Zip	:	92018
Country	:	US
Telephone Number	:	760-720-7687
Fax Number	:	760-720-7687

Provider Business Practice Location Address
First Line	:	1902 WRIGHT PL STE 200
Second Line	:
City	:	CARLSBAD
State	:	CA
Zip	:	92008-6583
Country	:	US
Telephone Number	:	760-720-7687
Fax Number	:	760-720-7687

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

Provider Enumeration Date	:	03/30/2007
Last Update Date	:	03/25/2011

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