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General NPI Number Information
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NPI Number | 1124673447
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Entity Type | Individual
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Provider Name | JOHN BRENT LAGUE PSYD
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Gender | Male
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Dates
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Enumeration Date | 08/04/2019
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Last Update Date | 08/04/2019
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Provider Practice Location Address
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Address Line | 1101 N PACIFIC AVE STE 204
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City | GLENDALE
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State | CA
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Zip | 91202-4316
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Country | US
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Telephone | 626-806-8652
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Fax |
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Provider Business Mailing Address
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Address Line | 202 N MADISON AVE
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City | MONROVIA
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State | CA
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Zip | 91016-1553
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Country | US
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Telephone | 626-806-8652
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | PSY24031
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License Number State | CA
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