Healthcare Provider Details

I. General information

NPI: 1982969085
Provider Name (Legal Business Name): ELVIN LANCE AHL MS, MDIV
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/05/2012
Last Update Date: 05/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2782 GATEWAY RD
CARLSBAD CA
92009-1730
US

IV. Provider business mailing address

1880 KEY LARGO RD
VISTA CA
92081-7007
US

V. Phone/Fax

Practice location:
  • Phone: 714-222-0331
  • Fax:
Mailing address:
  • Phone: 714-222-0331
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number86028
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: