Provider Demographics
NPI:1528839206
Name:GANSEREIT, LYDIA
Entity type:Individual
Prefix:
First Name:LYDIA
Middle Name:
Last Name:GANSEREIT
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 1:278 DUNCAN ROAD
Mailing Address - Street 2:
Mailing Address - City:PINON HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92372
Mailing Address - Country:US
Mailing Address - Phone:949-929-8049
Mailing Address - Fax:
Practice Address - Street 1:1500 S HAVEN AVE STE 250
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91761-2973
Practice Address - Country:US
Practice Address - Phone:909-749-5204
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-11
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician