MEDICARE: MRS. LYDIANA GARCIA-SUAZO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	PY11720	FL
2	103TC1900X	Counseling Psychologist	3838	PR
3	103TC1900X	Counseling Psychologist	PSY24888	CA
4	103TC0700X	Clinical Psychologist	PSY24888	CA

General Provider Information

NPI Number	:	1235387994
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LYDIANA GARCIA-SUAZO

Provider Business Mailing Address
First Line	:	30825 PENNY SURF LOOP
Second Line	:
City	:	WESLEY CHAPEL
State	:	FL
Zip	:	33545-2306
Country	:	US
Telephone Number	:	310-592-3333
Fax Number	:

Provider Business Practice Location Address
First Line	:	3031 N SAN FERNANDO BLVD STE 100
Second Line	:
City	:	BURBANK
State	:	CA
Zip	:	91504-4704
Country	:	US
Telephone Number	:	310-592-5333
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/05/2008
Last Update Date	:	06/14/2023

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