Basic Information
| Provider Information | |||||||||
| NPI: | 1447819685 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VANBEENEN | ||||||||
| FirstName: | LEEANN | ||||||||
| MiddleName: | ROSE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2489 LAKE TAHOE BLVD STE 23 | ||||||||
| Address2: | |||||||||
| City: | SOUTH LAKE TAHOE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 961507739 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5305783839 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2489 LAKE TAHOE BLVD | ||||||||
| Address2: | |||||||||
| City: | SOUTH LAKE TAHOE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 961507728 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5305783839 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2019 | ||||||||
| LastUpdateDate: | 06/11/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106E00000X | Y2148208 | CA | N | 106S00000X | Y2148208 | CA | N | 103K00000X | Y2148208 | CA | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
ID Information
| ID | Type | State | Issuer | Description | 04211999 | 05 | CA | MEDICAID |