Provider Demographics
NPI:1013912443
Name:BECKER, VANCE B (PHD)
Entity Type:Individual
Prefix:DR
First Name:VANCE
Middle Name:B
Last Name:BECKER
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 1:1451 QUAIL ST
Mailing Address - Street 2:STE 102
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-2747
Mailing Address - Country:US
Mailing Address - Phone:949-757-1113
Mailing Address - Fax:949-757-1114
Practice Address - Street 1:1451 QUAIL ST
Practice Address - Street 2:STE 102
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-2747
Practice Address - Country:US
Practice Address - Phone:949-757-1113
Practice Address - Fax:949-757-1114
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-13
Last Update Date:2010-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY007654103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACP7654Medicare ID - Type UnspecifiedLICENSED PSYCHOLOGIST