Healthcare Provider Details

I. General information

NPI: 1518519370
Provider Name (Legal Business Name): LYRICE A MARSH M.DIV
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2019
Last Update Date: 07/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25421 MAXIMUS ST
MISSION VIEJO CA
92691-4647
US

IV. Provider business mailing address

655 S MAIN ST # 165
ORANGE CA
92868-4690
US

V. Phone/Fax

Practice location:
  • Phone: 310-402-9079
  • Fax:
Mailing address:
  • Phone: 310-402-9079
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: