Provider Demographics
NPI:1669838090
Name:LAC, LIEN KIM
Entity Type:Individual
Prefix:
First Name:LIEN
Middle Name:KIM
Last Name:LAC
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 1:910 PLEASANT GROVE BLVD STE 120-182
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95678-6193
Mailing Address - Country:US
Mailing Address - Phone:510-599-8139
Mailing Address - Fax:
Practice Address - Street 1:915 HIGHLAND POINTE DR STE 250
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95678
Practice Address - Country:US
Practice Address - Phone:510-599-8139
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-14
Last Update Date:2019-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA111866106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist