Provider Demographics
NPI:1326168501
Name:VON IMM, LYDIA (PHD)
Entity Type:Individual
Prefix:DR
First Name:LYDIA
Middle Name:
Last Name:VON IMM
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:PO BOX 2421
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92018
Mailing Address - Country:US
Mailing Address - Phone:760-720-7687
Mailing Address - Fax:760-720-7687
Practice Address - Street 1:1902 WRIGHT PL STE 200
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92008-6583
Practice Address - Country:US
Practice Address - Phone:760-720-7687
Practice Address - Fax:760-720-7687
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-30
Last Update Date:2011-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY12267103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACP12267Medicare ID - Type Unspecified