Healthcare Provider Details

I. General information

NPI: 1790220671
Provider Name (Legal Business Name): LYNLEE ANN LYCKBERG REG PSYCH ASSOCIATE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/30/2016
Last Update Date: 04/26/2025
Certification Date: 04/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

399 TAYLOR BLVD STE 210
PLEASANT HILL CA
94523-2287
US

IV. Provider business mailing address

232 BROCK RD
NEVADA CITY CA
95959-2902
US

V. Phone/Fax

Practice location:
  • Phone: 530-575-5362
  • Fax:
Mailing address:
  • Phone: 530-575-5362
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code102L00000X
TaxonomyPsychoanalyst
License Number
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSB94028907
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: