Healthcare Provider Details

I. General information

NPI: 1700356052
Provider Name (Legal Business Name): LIANE MITCHUM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2018
Last Update Date: 05/12/2021
Certification Date: 05/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 THE CITY DR S
ORANGE CA
92868-3205
US

IV. Provider business mailing address

301 THE CITY DR S
ORANGE CA
92868-3205
US

V. Phone/Fax

Practice location:
  • Phone: 714-935-6363
  • Fax:
Mailing address:
  • Phone: 714-935-6363
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: