Basic Information
| Provider Information | |||||||||
| NPI: | 1184803280 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | OASIS | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | PROVIDENCE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| OtherNamePrefix: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1900 E LA PALMA AVE | ||||||||
| Address2: | 101 | ||||||||
| City: | ANAHEIM | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928051647 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7143993480 | ||||||||
| FaxNumber: | 7143993481 | ||||||||
| Practice Location | |||||||||
| Address1: | 1900 E LA PALMA AVE | ||||||||
| Address2: | 101 | ||||||||
| City: | ANAHEIM | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928051647 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7143993480 | ||||||||
| FaxNumber: | 7143993481 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2007 | ||||||||
| LastUpdateDate: | 10/25/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CHAMBLESS | ||||||||
| AuthorizedOfficialFirstName: | SHEARLY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PROGRAM DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7143993480 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | LCSW | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | Y | Agencies | Case Management |
No ID Information.