Healthcare Provider Details

I. General information

NPI: 1871076430
Provider Name (Legal Business Name): HOLLY SHUBIN LEP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: HOLLY VICTOR

II. Dates (important events)

Enumeration Date: 09/10/2018
Last Update Date: 09/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 S EAST ST
ANAHEIM CA
92805-5749
US

IV. Provider business mailing address

1001 S EAST ST
ANAHEIM CA
92805-5749
US

V. Phone/Fax

Practice location:
  • Phone: 714-517-7500
  • Fax:
Mailing address:
  • Phone: 714-517-7500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number3181
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: