Provider Demographics
NPI:1093859035
Name:BANGTSON, LYDIA S (PHD)
Entity Type:Individual
Prefix:DR
First Name:LYDIA
Middle Name:S
Last Name:BANGTSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 W EULALIA ST
Mailing Address - Street 2:SUITE 301
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91204-2849
Mailing Address - Country:US
Mailing Address - Phone:818-240-0108
Mailing Address - Fax:818-240-0301
Practice Address - Street 1:222 W EULALIA ST
Practice Address - Street 2:SUITE 301
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91204-2849
Practice Address - Country:US
Practice Address - Phone:818-240-0108
Practice Address - Fax:818-240-0301
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 18278103TC0700X
CAPSY18278103TF0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic