Healthcare Provider Details

I. General information

NPI: 1174239636
Provider Name (Legal Business Name): DRLULLABY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/27/2023
Last Update Date: 09/12/2023
Certification Date: 09/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4533 MACARTHUR BLVD
NEWPORT BEACH CA
92660-2059
US

IV. Provider business mailing address

1101 DAVIS ST STE 5767
EVANSTON IL
60201-5945
US

V. Phone/Fax

Practice location:
  • Phone: 844-475-3379
  • Fax:
Mailing address:
  • Phone: 844-475-3379
  • Fax: 855-644-2981

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State

VIII. Authorized Official

Name: LISA ANN MEDALIE
Title or Position: CEO
Credential:
Phone: 844-475-3379