1013101351 NPI number — CHANTELLE LA TREICE MILLER PSY.D.

Table of content: CHANTELLE LA TREICE MILLER PSY.D. (NPI 1013101351)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013101351 NPI number — CHANTELLE LA TREICE MILLER PSY.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MILLER
Provider First Name:
CHANTELLE
Provider Middle Name:
LA TREICE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PSY.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1013101351
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/14/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2500 WILSHIRE BLVD FL 5
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOS ANGELES
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90057-4303
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
213-639-0266
Provider Business Mailing Address Fax Number:
213-388-1473

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6617 5TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOS ANGELES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90043-4532
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-404-4809
Provider Business Practice Location Address Fax Number:
213-388-1473
Provider Enumeration Date:
08/29/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225C00000X , with the licence number:  RPS2009026 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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