Provider Demographics
NPI:1093063745
Name:LEZAMA, MATTHEW GLEN (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:GLEN
Last Name:LEZAMA
Suffix:
Gender:M
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 N CEDAR ST APT 204
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91206-5704
Mailing Address - Country:US
Mailing Address - Phone:925-785-9123
Mailing Address - Fax:
Practice Address - Street 1:150 S LOS ROBLES AVE STE 850
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91101-4630
Practice Address - Country:US
Practice Address - Phone:888-588-8995
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-28
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA95010135363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program