Healthcare Provider Details

I. General information

NPI: 1568629368
Provider Name (Legal Business Name): ANNIE A LY MFT INTERN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/20/2008
Last Update Date: 02/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

769 W BLAINE ST SUITE 241
RIVERSIDE CA
92507-3970
US

IV. Provider business mailing address

769 W BLAINE ST
RIVERSIDE CA
92507-3970
US

V. Phone/Fax

Practice location:
  • Phone: 951-358-5196
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: