Provider Demographics
NPI:1104861152
Name:ZIMMERMAN, LANCE Y (PHD)
Entity Type:Individual
Prefix:
First Name:LANCE
Middle Name:Y
Last Name:ZIMMERMAN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4126 S DEMAREE ST
Mailing Address - Street 2:VISALIA
Mailing Address - City:VISALIA
Mailing Address - State:CA
Mailing Address - Zip Code:93277-9514
Mailing Address - Country:US
Mailing Address - Phone:559-393-7465
Mailing Address - Fax:559-754-2107
Practice Address - Street 1:4126 S DEMAREE ST
Practice Address - Street 2:VISALIA
Practice Address - City:VISALIA
Practice Address - State:CA
Practice Address - Zip Code:93277-9514
Practice Address - Country:US
Practice Address - Phone:559-393-7465
Practice Address - Fax:559-754-2107
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-16
Last Update Date:2015-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY27555103TC0700X
CARA856708101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO495299919Medicaid
MO1255331005OtherGROUP NPI
CA1104861152Medicare NSC