Provider Demographics
NPI:1679777502
Name:LYDA, MOLLY RENEE (MA)
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:RENEE
Last Name:LYDA
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4335 VAN NUYS BLVD # 172
Mailing Address - Street 2:
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91403-3727
Mailing Address - Country:US
Mailing Address - Phone:818-671-8953
Mailing Address - Fax:
Practice Address - Street 1:14140 VENTURA BLVD STE 206
Practice Address - Street 2:
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91423-2750
Practice Address - Country:US
Practice Address - Phone:818-671-8953
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA51060106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist