Basic Information
| Provider Information | |||||||||
| NPI: | 1811566797 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ENTRIKIN | ||||||||
| FirstName: | MAKENNA | ||||||||
| MiddleName: | LEE | ||||||||
| NamePrefix: | MISS | ||||||||
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| Credential: | BA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7691 CREOLE PL UNIT 5 | ||||||||
| Address2: | |||||||||
| City: | RANCHO CUCAMONGA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917397522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9093673974 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2155 CHICAGO AVE STE 203 | ||||||||
| Address2: | |||||||||
| City: | RIVERSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925072209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9513576926 | ||||||||
| FaxNumber: | 8555682494 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2021 | ||||||||
| LastUpdateDate: | 06/24/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | N | Behavioral Health & Social Service Providers | Behavioral Analyst | 106S00000X | Y |
No ID Information.