Provider Demographics
NPI:1578558573
Name:HART, LANCE R (PHD)
Entity Type:Individual
Prefix:
First Name:LANCE
Middle Name:R
Last Name:HART
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 1:1 S MAIN ST
Mailing Address - Street 2:#2
Mailing Address - City:BRANFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06405-3872
Mailing Address - Country:US
Mailing Address - Phone:203-488-3078
Mailing Address - Fax:
Practice Address - Street 1:1 S MAIN ST
Practice Address - Street 2:#2
Practice Address - City:BRANFORD
Practice Address - State:CT
Practice Address - Zip Code:06405-3872
Practice Address - Country:US
Practice Address - Phone:203-488-3078
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000576103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT060000576CT01OtherANTHEM