Provider Demographics
NPI:1619726643
Name:MAJOR LANCE, MINGON VALENCIA (RADT)
Entity type:Individual
Prefix:
First Name:MINGON
Middle Name:VALENCIA
Last Name:MAJOR LANCE
Suffix:
Gender:F
Credentials:RADT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1721 N FAIRFAX DR APT D
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92404-5500
Mailing Address - Country:US
Mailing Address - Phone:818-305-1471
Mailing Address - Fax:
Practice Address - Street 1:1721 N FAIRFAX DR APT D
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92404-5500
Practice Address - Country:US
Practice Address - Phone:818-305-1471
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-13
Last Update Date:2024-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1509460623101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)