Healthcare Provider Details

I. General information

NPI: 1093063745
Provider Name (Legal Business Name): MATTHEW GLEN LEZAMA PMHNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2012
Last Update Date: 01/12/2023
Certification Date: 12/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 S LOS ROBLES AVE STE 850
PASADENA CA
91101-4630
US

IV. Provider business mailing address

305 N CEDAR ST APT 204
GLENDALE CA
91206-5704
US

V. Phone/Fax

Practice location:
  • Phone: 888-588-8995
  • Fax:
Mailing address:
  • Phone: 925-785-9123
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95010135
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: