Provider Demographics
NPI:1952471898
Name:DOME, LANCE JUDDSON (PHD, LMFT)
Entity Type:Individual
Prefix:DR
First Name:LANCE
Middle Name:JUDDSON
Last Name:DOME
Suffix:
Gender:M
Credentials:PHD, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 W SERGEANT COURT DR STE 201
Mailing Address - Street 2:
Mailing Address - City:SARATOGA SPRINGS
Mailing Address - State:UT
Mailing Address - Zip Code:84045-5809
Mailing Address - Country:US
Mailing Address - Phone:801-341-1919
Mailing Address - Fax:
Practice Address - Street 1:24 W SERGEANT COURT DR STE 201
Practice Address - Street 2:
Practice Address - City:SARATOGA SPRINGS
Practice Address - State:UT
Practice Address - Zip Code:84045-5809
Practice Address - Country:US
Practice Address - Phone:801-341-1919
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2020-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6890279-3902106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCPENDINGMedicaid