Healthcare Provider Details

I. General information

NPI: 1861635013
Provider Name (Legal Business Name): LYDIA S GLASS PHD PSYCHOLOGICAL & MEDIATION SERVICES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/16/2009
Last Update Date: 04/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 E DEL MAR BLVD STE 210
PASADENA CA
91105-2551
US

IV. Provider business mailing address

200 E DEL MAR BLVD STE 210
PASADENA CA
91105-2551
US

V. Phone/Fax

Practice location:
  • Phone: 626-792-4153
  • Fax: 626-930-0626
Mailing address:
  • Phone: 626-792-4153
  • Fax: 626-930-0626

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberPSY13464
License Number StateCA

VIII. Authorized Official

Name: DR. LYDIA S GLASS
Title or Position: PRESIDENT
Credential:
Phone: 626-792-4153