Healthcare Provider Details

I. General information

NPI: 1245484807
Provider Name (Legal Business Name): LAURA S. RYDELL M.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/10/2008
Last Update Date: 11/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26302 LA PAZ RD SUITE 201
MISSION VIEJO CA
92691-5313
US

IV. Provider business mailing address

26302 LA PAZ RD SUITE 201
MISSION VIEJO CA
92691-5313
US

V. Phone/Fax

Practice location:
  • Phone: 949-586-9848
  • Fax: 949-586-7470
Mailing address:
  • Phone: 949-586-9848
  • Fax: 949-586-7470

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberLEP 1640
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFT 20647
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: