1710011309 NPI number — GLENDA YVONNE BOATNER MSW, ACSW

Table of content: GLENDA YVONNE BOATNER MSW, ACSW (NPI 1710011309)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710011309 NPI number — GLENDA YVONNE BOATNER MSW, ACSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOATNER
Provider First Name:
GLENDA
Provider Middle Name:
YVONNE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MSW, ACSW
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:
1710011309
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
487 N 5TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BANNING
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92220-4637
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-629-2400
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2555 E COLORADO BLVD
Provider Second Line Business Practice Location Address:
SUITE 100-101
Provider Business Practice Location Address City Name:
PASADENA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91107-6622
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
626-577-2261
Provider Business Practice Location Address Fax Number:
626-577-2543
Provider Enumeration Date:
03/15/2007

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: 101YM0800X , with the licence number:  ASW12440 , 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)

  • Identifier: ICAN752 . This is a "DMH STAFF CODE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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