Provider Demographics
NPI:1770302317
Name:PELAYO, LILLY BETH (ANMT)
Entity type:Individual
Prefix:
First Name:LILLY BETH
Middle Name:
Last Name:PELAYO
Suffix:
Gender:F
Credentials:ANMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11971 RICKY AVE
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92840-1746
Mailing Address - Country:US
Mailing Address - Phone:714-823-0318
Mailing Address - Fax:
Practice Address - Street 1:600 S HARBOR BLVD
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92805-4526
Practice Address - Country:US
Practice Address - Phone:714-823-0318
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-09
Last Update Date:2024-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA77061225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty