Provider Demographics
NPI:1326563529
Name:LIVELY COOKSON, LYNETTE W (PSYD)
Entity type:Individual
Prefix:DR
First Name:LYNETTE
Middle Name:W
Last Name:LIVELY COOKSON
Suffix:
Gender:X
Credentials:PSYD
Other - Prefix:MISS
Other - First Name:LYNETTE
Other - Middle Name:A
Other - Last Name:WALKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11230 SORRENTO VALLEY RD STE 220
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92121-1300
Mailing Address - Country:US
Mailing Address - Phone:858-648-5367
Mailing Address - Fax:
Practice Address - Street 1:11230 SORRENTO VALLEY RD STE 220
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-1300
Practice Address - Country:US
Practice Address - Phone:858-648-5367
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-08
Last Update Date:2024-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA35422103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical