Provider Demographics
NPI:1639300080
Name:GOREN, LYNN (PHD)
Entity Type:Individual
Prefix:DR
First Name:LYNN
Middle Name:
Last Name:GOREN
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 1:16494 EL HITO PL
Mailing Address - Street 2:
Mailing Address - City:PACIFIC PALISADES
Mailing Address - State:CA
Mailing Address - Zip Code:90272-2339
Mailing Address - Country:US
Mailing Address - Phone:310-454-6790
Mailing Address - Fax:
Practice Address - Street 1:16494 EL HITO PL
Practice Address - Street 2:
Practice Address - City:PACIFIC PALISADES
Practice Address - State:CA
Practice Address - Zip Code:90272-2339
Practice Address - Country:US
Practice Address - Phone:310-454-6790
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-03
Last Update Date:2009-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
102L00000X
CAPSY13693103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No102L00000XBehavioral Health & Social Service ProvidersPsychoanalyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAR86261Medicare UPIN