Basic Information
| Provider Information | |||||||||
| NPI: | 1790915619 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LIDOR | ||||||||
| FirstName: | ORI | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2235 RIVER RUN DR | ||||||||
| Address2: | #3206 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921085887 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8189430457 | ||||||||
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| Practice Location | |||||||||
| Address1: | 734 10TH AVE | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921016502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6192394663 | ||||||||
| FaxNumber: | 6192393045 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2009 | ||||||||
| LastUpdateDate: | 07/27/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.