Provider Demographics
NPI:1750831095
Name:PORTNOFF, LANCE (PHD)
Entity Type:Individual
Prefix:
First Name:LANCE
Middle Name:
Last Name:PORTNOFF
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 1:814 W CENTER AVE
Mailing Address - Street 2:SUITE H
Mailing Address - City:VISALIA
Mailing Address - State:CA
Mailing Address - Zip Code:93291-6046
Mailing Address - Country:US
Mailing Address - Phone:805-459-1961
Mailing Address - Fax:
Practice Address - Street 1:814 W CENTER AVE
Practice Address - Street 2:SUITE H
Practice Address - City:VISALIA
Practice Address - State:CA
Practice Address - Zip Code:93291-6046
Practice Address - Country:US
Practice Address - Phone:805-459-1961
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-11
Last Update Date:2016-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY7522103TF0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic