Healthcare Provider Details

I. General information

NPI: 1275463184
Provider Name (Legal Business Name): LANCE DEREK DELGADO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2026
Last Update Date: 05/21/2026
Certification Date: 05/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33353 YUCAIPA BLVD
YUCAIPA CA
92399-2018
US

IV. Provider business mailing address

11774 AVALON AVE
YUCAIPA CA
92399-2823
US

V. Phone/Fax

Practice location:
  • Phone: 951-465-3664
  • Fax:
Mailing address:
  • Phone: 909-732-8906
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: