Provider Demographics
NPI:1821109018
Name:VAN HAGEN, JOHN LESTER (PHD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:LESTER
Last Name:VAN HAGEN
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 1:4252 25TH ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94114-3619
Mailing Address - Country:US
Mailing Address - Phone:415-282-1210
Mailing Address - Fax:415-648-9836
Practice Address - Street 1:35 VICENTE ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94127-1301
Practice Address - Country:US
Practice Address - Phone:415-282-1210
Practice Address - Fax:415-648-9836
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY4469103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00PL44691Medicare ID - Type UnspecifiedCLINICAL PSYCHOLOGIST