Provider Demographics
NPI:1124537303
Name:LEZAMA, VICTOR MANUEL JR
Entity Type:Individual
Prefix:
First Name:VICTOR
Middle Name:MANUEL
Last Name:LEZAMA
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:265 SAN JACINTO RIVER RD
Mailing Address - Street 2:
Mailing Address - City:LAKE ELSINORE
Mailing Address - State:CA
Mailing Address - Zip Code:92530-4400
Mailing Address - Country:US
Mailing Address - Phone:951-674-9243
Mailing Address - Fax:951-674-9635
Practice Address - Street 1:265 SAN JACINTO RIVER RD
Practice Address - Street 2:
Practice Address - City:LAKE ELSINORE
Practice Address - State:CA
Practice Address - Zip Code:92530-4400
Practice Address - Country:US
Practice Address - Phone:951-674-9243
Practice Address - Fax:951-674-9635
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-20
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health