1104584382 NPI number — MRS. LAURA MILENA CHANNER MSW, LCSW

Table of content: MRS. LAURA MILENA CHANNER MSW, LCSW (NPI 1104584382)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104584382 NPI number — MRS. LAURA MILENA CHANNER MSW, LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CHANNER
Provider First Name:
LAURA
Provider Middle Name:
MILENA
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MSW, LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CASTELLANOS MARTIN
Provider Other First Name:
LAURA
Provider Other Middle Name:
MILENA
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MSW
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1104584382
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/29/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2411 SUNSET DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RIVERSIDE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92506-3469
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
951-454-8642
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3125 MYERS ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RIVERSIDE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92503-5527
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
951-358-4840
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/03/2021

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: 1041C0700X , with the licence number:  LCSW107693 , 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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