Basic Information
| Provider Information | |||||||||
| NPI: | 1639319544 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LARET | ||||||||
| FirstName: | VANETTA | ||||||||
| MiddleName: | DEE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | I | ||||||||
| Credential: | MFTI | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BRANSCUM | ||||||||
| OtherFirstName: | VANETTA | ||||||||
| OtherMiddleName: | DEE | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | I | ||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 222 E MAIN ST | ||||||||
| Address2: | SUITE 117 | ||||||||
| City: | BARSTOW | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923112361 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7602551496 | ||||||||
| FaxNumber: | 7602552542 | ||||||||
| Practice Location | |||||||||
| Address1: | 222 E MAIN ST | ||||||||
| Address2: | SUITE 117 | ||||||||
| City: | BARSTOW | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923112361 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7602551496 | ||||||||
| FaxNumber: | 7602552542 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/05/2009 | ||||||||
| LastUpdateDate: | 10/13/2011 | ||||||||
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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 | 106H00000X | 63900 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.