Healthcare Provider Details

I. General information

NPI: 1982967014
Provider Name (Legal Business Name): IVY K LAI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2012
Last Update Date: 01/24/2023
Certification Date: 01/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9353 VALLEY BLVD STE C
ROSEMEAD CA
91770-1923
US

IV. Provider business mailing address

9353 VALLEY BLVD STE C
ROSEMEAD CA
91770-1923
US

V. Phone/Fax

Practice location:
  • Phone: 626-842-7578
  • Fax:
Mailing address:
  • Phone: 626-842-7578
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code167G00000X
TaxonomyLicensed Psychiatric Technician
License Number36551
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: