Healthcare Provider Details

I. General information

NPI: 1902002785
Provider Name (Legal Business Name): ROBERTO FABIAN LAZCANO PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/27/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3301 E 12TH ST SUITE 259
OAKLAND CA
94601-3424
US

IV. Provider business mailing address

2094 DONALD DR
MORAGA CA
94556-1402
US

V. Phone/Fax

Practice location:
  • Phone: 510-269-9084
  • Fax:
Mailing address:
  • Phone: 510-612-4659
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number21177
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: