Provider Demographics
NPI:1861635013
Name:LYDIA S GLASS PHD PSYCHOLOGICAL & MEDIATION SERVICES INC
Entity Type:Organization
Organization Name:LYDIA S GLASS PHD PSYCHOLOGICAL & MEDIATION SERVICES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LYDIA
Authorized Official - Middle Name:S
Authorized Official - Last Name:GLASS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:626-792-4153
Mailing Address - Street 1:200 E DEL MAR BLVD STE 210
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91105-2551
Mailing Address - Country:US
Mailing Address - Phone:626-792-4153
Mailing Address - Fax:626-930-0626
Practice Address - Street 1:200 E DEL MAR BLVD STE 210
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-2551
Practice Address - Country:US
Practice Address - Phone:626-792-4153
Practice Address - Fax:626-930-0626
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-16
Last Update Date:2009-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY13464101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACP13464OtherMEDICARE PTAN