Provider Demographics
NPI:1790220671
Name:LYCKBERG, LYNLEE ANN (REG PSYCH ASSOCIATE)
Entity type:Individual
Prefix:DR
First Name:LYNLEE
Middle Name:ANN
Last Name:LYCKBERG
Suffix:
Gender:F
Credentials:REG PSYCH ASSOCIATE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:232 BROCK RD
Mailing Address - Street 2:
Mailing Address - City:NEVADA CITY
Mailing Address - State:CA
Mailing Address - Zip Code:95959-2902
Mailing Address - Country:US
Mailing Address - Phone:530-575-5362
Mailing Address - Fax:
Practice Address - Street 1:399 TAYLOR BLVD STE 210
Practice Address - Street 2:
Practice Address - City:PLEASANT HILL
Practice Address - State:CA
Practice Address - Zip Code:94523-2287
Practice Address - Country:US
Practice Address - Phone:530-575-5362
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-30
Last Update Date:2025-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YM0800X, 102L00000X
CAPSB94028907103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No102L00000XBehavioral Health & Social Service ProvidersPsychoanalyst