Provider Demographics
NPI:1194214056
Name:UCHIDA, LYSSA LYNN (MT)
Entity Type:Individual
Prefix:
First Name:LYSSA
Middle Name:LYNN
Last Name:UCHIDA
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:702 W HAMILTON PL APT 8
Mailing Address - Street 2:
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90731-6371
Mailing Address - Country:US
Mailing Address - Phone:310-293-9382
Mailing Address - Fax:
Practice Address - Street 1:312 S CATALINA AVE STE E
Practice Address - Street 2:
Practice Address - City:REDONDO BEACH
Practice Address - State:CA
Practice Address - Zip Code:90277-3622
Practice Address - Country:US
Practice Address - Phone:310-293-9382
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-07
Last Update Date:2018-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA37859225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist