Provider Demographics
NPI:1982106100
Name:VAN, LENA
Entity Type:Individual
Prefix:
First Name:LENA
Middle Name:
Last Name:VAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1629 GLENCOE DR
Mailing Address - Street 2:
Mailing Address - City:LEMON GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:91945-4031
Mailing Address - Country:US
Mailing Address - Phone:619-565-7858
Mailing Address - Fax:619-374-7134
Practice Address - Street 1:1301 E ORANGEWOOD AVE
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92805-6807
Practice Address - Country:US
Practice Address - Phone:800-249-1266
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-03
Last Update Date:2023-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
CA1-21-49404103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician