Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 102L00000X | Psychologist | PSY 24783 | CA |
Y | 103T00000X | Psychologist | PSY 24783 | CA |
N | 103TA0700X | Adult Development & Aging Psychologist | PSY 24783 | CA |
N | 103G00000X | Clinical Psychologist | PSY 24783 | CA |
N | 103TC0700X | Clinical Psychologist | PSY 24783 | CA |
N | 103TE1100X | Exercise & Sports Psychologist | PSY 24783 | CA |
N | 103TH0004X | Health Psychologist | PSY 24783 | CA |
N | 103TH0100X | Health Service | PSY 24783 | CA |
N | 103TR0400X | Rehabilitation Psychologist | PSY 24783 | CA |
NPI | 1346679404 |
---|---|
Provider Name | Dr. Mollie Lyddane |
First Address | Richmond, CA 94804-7441 |
Second Address | Richmond, CA 94804-7441 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 08/11/2013 |
Last Update Date | 08/11/2013 |