Provider Demographics
NPI:1073327896
Name:LANZ, DESIREE
Entity type:Individual
Prefix:
First Name:DESIREE
Middle Name:
Last Name:LANZ
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17862 17TH ST STE 107
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-2170
Mailing Address - Country:US
Mailing Address - Phone:310-779-5497
Mailing Address - Fax:
Practice Address - Street 1:17862 17TH ST STE 107
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-2170
Practice Address - Country:US
Practice Address - Phone:310-779-5497
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-03
Last Update Date:2025-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA153302106H00000X
106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist