Healthcare Provider Details

I. General information

NPI: 1841107885
Provider Name (Legal Business Name): NICOLAS MATEO DE LIRA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/25/2026
Last Update Date: 08/25/2026
Certification Date: 08/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2535 W HOUSTON AVE
ANAHEIM CA
92801-1434
US

IV. Provider business mailing address

2535 W HOUSTON AVE
ANAHEIM CA
92801-1434
US

V. Phone/Fax

Practice location:
  • Phone: 714-473-6635
  • Fax:
Mailing address:
  • Phone: 714-473-6635
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: