Provider Demographics
NPI:1568629368
Name:LY, ANNIE A (MFT INTERN)
Entity type:Individual
Prefix:
First Name:ANNIE
Middle Name:A
Last Name:LY
Suffix:
Gender:F
Credentials:MFT INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:769 W BLAINE ST
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92507-3970
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:769 W BLAINE ST
Practice Address - Street 2:SUITE 241
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507-3970
Practice Address - Country:US
Practice Address - Phone:951-358-5196
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-20
Last Update Date:2014-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program