Healthcare Provider Details

I. General information

NPI: 1467783738
Provider Name (Legal Business Name): GINNY LIWANPO PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/26/2010
Last Update Date: 01/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 DOVE ST #155
NEWPORT BEACH CA
92660-2839
US

IV. Provider business mailing address

1101 DOVE ST #155
NEWPORT BEACH CA
92660-2839
US

V. Phone/Fax

Practice location:
  • Phone: 949-491-6135
  • Fax: 714-362-8783
Mailing address:
  • Phone: 949-491-6135
  • Fax: 714-362-8783

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY 20910
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License NumberPSY 20910
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License NumberPSY 20910
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: