Basic Information
| Provider Information | |||||||||
| NPI: | 1861888497 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LAMPHERE | ||||||||
| FirstName: | THERESA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5607 MOUNT MURPHY ROAD | ||||||||
| Address2: | |||||||||
| City: | GARDEN VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95667 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5303339460 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5607 MOUNT MURPHY ROAD | ||||||||
| Address2: | |||||||||
| City: | GARDEN VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95667 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5303339460 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2015 | ||||||||
| LastUpdateDate: | 04/10/2015 | ||||||||
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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 | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | CCAP | 01 | CA | CCAP | OTHER |