Basic Information
Provider Information | |||||||||
NPI: | 1366952079 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FISH | ||||||||
FirstName: | NATALIE | ||||||||
MiddleName: | LANAE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 10531 POLAND PL | ||||||||
Address2: |   | ||||||||
City: | BANNING | ||||||||
State: | CA | ||||||||
PostalCode: | 922201561 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9512061173 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 5870 ARLINGTON AVE # 103 | ||||||||
Address2: |   | ||||||||
City: | RIVERSIDE | ||||||||
State: | CA | ||||||||
PostalCode: | 925042037 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9516836596 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/08/2017 | ||||||||
LastUpdateDate: | 02/24/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/24/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 8753-R | CA | N |   | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 175T00000X |   | CA | N |   |   |   |   | 101YA0400X | 198753 | CA | Y |   | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
ID | Type | State | Issuer | Description | 8753-R | 01 | CA | CAADE | OTHER |