Provider Demographics
NPI:1164841615
Name:LYMATH, BREANN
Entity Type:Individual
Prefix:
First Name:BREANN
Middle Name:
Last Name:LYMATH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 742
Mailing Address - Street 2:
Mailing Address - City:FOLSOM
Mailing Address - State:CA
Mailing Address - Zip Code:95763-0742
Mailing Address - Country:US
Mailing Address - Phone:916-237-7149
Mailing Address - Fax:
Practice Address - Street 1:111 WOODMERE RD STE 100
Practice Address - Street 2:
Practice Address - City:FOLSOM
Practice Address - State:CA
Practice Address - Zip Code:95630-4750
Practice Address - Country:US
Practice Address - Phone:916-237-7149
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-14
Last Update Date:2021-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP2500X, 390200000X, 106H00000X
CA109434106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program