MEDICARE: LYDIA RUARK PH.D.

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	103T00000X	Psychologist	PSY10329	CA

General Provider Information

NPI Number	:	1992103899
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LYDIA RUARK PH.D.

Provider Business Mailing Address
First Line	:	9854 NATIONAL BLVD STE 372
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90034-2713
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3020 CASTLE HEIGHTS AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90034-2753
Country	:	US
Telephone Number	:	310-837-7979
Fax Number	:

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

Provider Enumeration Date	:	12/09/2014
Last Update Date	:	12/09/2014

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