MEDICARE: DR. LIDETH ORTEGA-VILLALOBOS PH.D.

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	PSY23640	CA

General Provider Information

NPI Number	:	1649644980
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LIDETH ORTEGA-VILLALOBOS PH.D.

Provider Business Mailing Address
First Line	:	1250 E WALNUT ST STE 110
Second Line	:
City	:	PASADENA
State	:	CA
Zip	:	91106-1877
Country	:	US
Telephone Number	:	626-470-3344
Fax Number	:

Provider Business Practice Location Address
First Line	:	1250 E WALNUT ST STE 110
Second Line	:
City	:	PASADENA
State	:	CA
Zip	:	91106-1877
Country	:	US
Telephone Number	:	626-470-3344
Fax Number	:

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

Provider Enumeration Date	:	11/24/2015
Last Update Date	:	11/24/2015

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