Basic Information
| Provider Information | |||||||||
| NPI: | 1699150771 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | POINDEXTER | ||||||||
| FirstName: | TERRAN | ||||||||
| MiddleName: | IMANI | ||||||||
| NamePrefix: | MISS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9145 PINON AVE | ||||||||
| Address2: | |||||||||
| City: | HESPERIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923453773 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7609007371 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2600 SW HOLDEN ST | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981263505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2069337000 | ||||||||
| FaxNumber: | 2069337101 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/30/2015 | ||||||||
| LastUpdateDate: | 07/30/2015 | ||||||||
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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 | 320800000X | E1873356 | CA | Y | Residential Treatment Facilities | Community Based Residential Treatment Facility, Mental Illness |
No ID Information.