Basic Information
| Provider Information | |||||||||
| NPI: | 1104384635 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LACKEY | ||||||||
| FirstName: | CHANNING | ||||||||
| MiddleName: | RENEE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13267 ROSWELL AVE | ||||||||
| Address2: | |||||||||
| City: | CHINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917104771 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9096808019 | ||||||||
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| Practice Location | |||||||||
| Address1: | 845 E ARROW HWY | ||||||||
| Address2: | |||||||||
| City: | POMONA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917672535 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9096241233 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/04/2019 | ||||||||
| LastUpdateDate: | 02/24/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.