Provider Demographics
NPI:1174556138
Name:PULVER, LANCE CRAIG (PHD)
Entity type:Individual
Prefix:
First Name:LANCE
Middle Name:CRAIG
Last Name:PULVER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 MARSHSIDE DR
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32080-5807
Mailing Address - Country:US
Mailing Address - Phone:904-471-3399
Mailing Address - Fax:
Practice Address - Street 1:24 CATHEDRAL PL
Practice Address - Street 2:SUITE 301
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32084-4473
Practice Address - Country:US
Practice Address - Phone:904-471-7888
Practice Address - Fax:904-471-7008
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY0005135103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling