Provider Demographics
NPI:1710376637
Name:VIELMA, LINA
Entity Type:Individual
Prefix:MS
First Name:LINA
Middle Name:
Last Name:VIELMA
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 1:2102 TIERRA LOMA DR
Mailing Address - Street 2:
Mailing Address - City:DIAMOND BAR
Mailing Address - State:CA
Mailing Address - Zip Code:91765-3137
Mailing Address - Country:US
Mailing Address - Phone:909-569-7557
Mailing Address - Fax:
Practice Address - Street 1:43423 DIVISION ST STE 401
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93535-4641
Practice Address - Country:US
Practice Address - Phone:909-569-7557
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-15
Last Update Date:2016-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist