Healthcare Provider Details

I. General information

NPI: 1851674584
Provider Name (Legal Business Name): MRS. HYDEE T LYSANH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MISS HYDEE A TORRES

II. Dates (important events)

Enumeration Date: 09/20/2011
Last Update Date: 09/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11721 TELEGRAPH RD
SANTA FE SPRINGS CA
90670-3674
US

IV. Provider business mailing address

11721 TELEGRAPH RD
SANTA FE SPRINGS CA
90670-3674
US

V. Phone/Fax

Practice location:
  • Phone: 562-949-8455
  • Fax: 562-949-4807
Mailing address:
  • Phone: 562-949-8455
  • Fax: 562-949-4807

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code167G00000X
TaxonomyLicensed Psychiatric Technician
License Number36128
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: