Provider Demographics
NPI:1033400841
Name:LIZAMA, MYRYAN A
Entity Type:Individual
Prefix:MRS
First Name:MYRYAN
Middle Name:A
Last Name:LIZAMA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MYRYAN
Other - Middle Name:A
Other - Last Name:LIZAMA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA
Mailing Address - Street 1:136 DIAMOND ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19122-1721
Mailing Address - Country:US
Mailing Address - Phone:267-271-6199
Mailing Address - Fax:
Practice Address - Street 1:136 DIAMOND ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19122-1721
Practice Address - Country:US
Practice Address - Phone:267-271-6199
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-27
Last Update Date:2011-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health