Provider Demographics
NPI:1457743015
Name:LANCE, PHILIP J (PHD)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:J
Last Name:LANCE
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 1:839 N JUNE ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90038-3511
Mailing Address - Country:US
Mailing Address - Phone:323-484-4212
Mailing Address - Fax:
Practice Address - Street 1:839 N JUNE ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90038-3511
Practice Address - Country:US
Practice Address - Phone:323-484-4212
Practice Address - Fax:323-454-2370
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-19
Last Update Date:2018-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY26965103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACB230771Medicare PIN