Basic Information
| Provider Information | |||||||||
| NPI: | 1376843672 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LAFONTAINE | ||||||||
| FirstName: | TAMARA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LMFT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | JENNINGS | ||||||||
| OtherFirstName: | TAMARA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LMFT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 34113 HILLSIDE DR | ||||||||
| Address2: | |||||||||
| City: | LAKE ELSINORE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925322952 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9518054671 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5870 ARLINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | RIVERSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925042037 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9516836596 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2010 | ||||||||
| LastUpdateDate: | 11/17/2021 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | LMFT81538 | CA | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 106H00000X | LMFT81538 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.