Provider Demographics
NPI:1013259001
Name:MCCLAIN, LYDIA DENISE
Entity type:Individual
Prefix:MISS
First Name:LYDIA
Middle Name:DENISE
Last Name:MCCLAIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2630 S HOBART BLVD APT 3
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90018-3532
Mailing Address - Country:US
Mailing Address - Phone:562-565-6339
Mailing Address - Fax:
Practice Address - Street 1:12440 IMPERIAL HWY
Practice Address - Street 2:
Practice Address - City:NORWALK
Practice Address - State:CA
Practice Address - Zip Code:90650-3177
Practice Address - Country:US
Practice Address - Phone:562-565-6339
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-18
Last Update Date:2013-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33951167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician