Provider Demographics
NPI:1053864298
Name:BLYTH, LIEN KIM-NGUYEN (MA)
Entity Type:Individual
Prefix:
First Name:LIEN
Middle Name:KIM-NGUYEN
Last Name:BLYTH
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2973 HARBOR BLVD STE 715
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626-3912
Mailing Address - Country:US
Mailing Address - Phone:714-584-9969
Mailing Address - Fax:
Practice Address - Street 1:2973 HARBOR BLVD STE 715
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-3912
Practice Address - Country:US
Practice Address - Phone:714-584-9969
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-24
Last Update Date:2021-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106H00000X
CA101708106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist