Basic Information
| Provider Information | |||||||||
| NPI: | 1477115111 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TREADWELL | ||||||||
| FirstName: | CHANEL | ||||||||
| MiddleName: | |||||||||
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| Credential: | MS, PPS, APCC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1416 | ||||||||
| Address2: | |||||||||
| City: | LOMA LINDA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923541416 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2067537305 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1845 BUSINESS CENTER DR STE 106 | ||||||||
| Address2: | |||||||||
| City: | SAN BERNARDINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 924083447 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9098048877 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/02/2019 | ||||||||
| LastUpdateDate: | 01/16/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | APCC5420 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.