Basic Information
| Provider Information | |||||||||
| NPI: | 1265069355 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PROTOTYPES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 831 E ARROW HWY | ||||||||
| Address2: | |||||||||
| City: | POMONA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917672535 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9096241233 | ||||||||
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| Practice Location | |||||||||
| Address1: | 831 E ARROW HWY | ||||||||
| Address2: | |||||||||
| City: | POMONA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917672535 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9096241233 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/26/2020 | ||||||||
| LastUpdateDate: | 03/27/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | JACKSON | ||||||||
| AuthorizedOfficialFirstName: | EVANNE | ||||||||
| AuthorizedOfficialMiddleName: | BREE | ||||||||
| AuthorizedOfficialTitleorPosition: | SUD COUNSELOR II | ||||||||
| AuthorizedOfficialTelephone: | 9096241233 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 03/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.