Basic Information
| Provider Information | |||||||||
| NPI: | 1174653968 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHAMPION | ||||||||
| FirstName: | LATERRA | ||||||||
| MiddleName: | WUNETTE | ||||||||
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| Credential: | M.S.W | ||||||||
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| Mailing Information | |||||||||
| Address1: | 18210 SANDY DR APT 203 | ||||||||
| Address2: | |||||||||
| City: | CANYON COUNTRY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913876063 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8188923423 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 15317 RAYEN ST | ||||||||
| Address2: | |||||||||
| City: | NORTH HILLS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913435117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8188923423 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 18165 | 01 | CA | ASSOCIATE SOCIAL WORKER | OTHER |