Provider Demographics
NPI:1669087573
Name:LIEN MITOBE, LAURA ANN (MA)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:ANN
Last Name:LIEN MITOBE
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:PO BOX 1365
Mailing Address - Street 2:
Mailing Address - City:LITTLEROCK
Mailing Address - State:CA
Mailing Address - Zip Code:93543-5365
Mailing Address - Country:US
Mailing Address - Phone:661-433-4385
Mailing Address - Fax:
Practice Address - Street 1:11108 EAST AVE. V 8
Practice Address - Street 2:
Practice Address - City:LITTLEROCK
Practice Address - State:CA
Practice Address - Zip Code:93543
Practice Address - Country:US
Practice Address - Phone:661-433-4385
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-09
Last Update Date:2020-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA17434101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health