Basic Information
| Provider Information | |||||||||
| NPI: | 1588153753 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VONDETTE | ||||||||
| FirstName: | CASEY | ||||||||
| MiddleName: | NICOLE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14272 HOOVER ST TRLR 27 | ||||||||
| Address2: | |||||||||
| City: | WESTMINSTER | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926834319 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7148642142 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2501 W EL SEGUNDO BLVD | ||||||||
| Address2: | |||||||||
| City: | HAWTHORNE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902503317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3237542816 | ||||||||
| FaxNumber: | 3237542828 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2018 | ||||||||
| LastUpdateDate: | 05/03/2018 | ||||||||
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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 | 101YA0400X | 9355-R | CA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.