Provider Demographics
NPI:1538679592
Name:LICHTENBERGER, PHILIP LYNN (BCBA)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:LYNN
Last Name:LICHTENBERGER
Suffix:
Gender:M
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1396 ROSELAWN AVE
Mailing Address - Street 2:
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91362-2031
Mailing Address - Country:US
Mailing Address - Phone:805-443-5859
Mailing Address - Fax:
Practice Address - Street 1:1396 ROSELAWN AVE
Practice Address - Street 2:
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91362-2031
Practice Address - Country:US
Practice Address - Phone:805-443-5859
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-04
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-14-16111103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst