Basic Information
| Provider Information | |||||||||
| NPI: | 1194842658 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHAVEZ | ||||||||
| FirstName: | JEANIE | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LMFT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KIELEY-CHAVEZ | ||||||||
| OtherFirstName: | JEANIE | ||||||||
| OtherMiddleName: | MARIE | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LMFT | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 415 W ROUTE 66 STE 202 | ||||||||
| Address2: | |||||||||
| City: | GLENDORA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917404335 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9098602166 | ||||||||
| FaxNumber: | 9099639543 | ||||||||
| Practice Location | |||||||||
| Address1: | 1370 VALLEY VISTA DR | ||||||||
| Address2: | SUITE 104 | ||||||||
| City: | DIAMOND BAR | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917653911 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9098602166 | ||||||||
| FaxNumber: | 9099639543 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2007 | ||||||||
| 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 | 106H00000X | MFC39590 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.