Basic Information
| Provider Information | |||||||||
| NPI: | 1003323718 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NIEVES | ||||||||
| FirstName: | LYZANDRA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 77 ESTABROOK ST APT 236 | ||||||||
| Address2: | |||||||||
| City: | SAN LEANDRO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945775933 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5107146552 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3075 CITRUS CIR STE 240 | ||||||||
| Address2: | |||||||||
| City: | WALNUT CREEK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945982667 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9252561100 | ||||||||
| FaxNumber: | 9252561122 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/03/2018 | ||||||||
| LastUpdateDate: | 11/20/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 1-21-55098 | CA | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.