Healthcare Provider Details

I. General information

NPI: 1528201894
Provider Name (Legal Business Name): VANESSA MCCLENNEY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/15/2009
Last Update Date: 10/19/2020
Certification Date: 10/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23950 PRADO LN
COLTON CA
92324-9734
US

IV. Provider business mailing address

14977 MT PALOMAR LN
FONTANA CA
92336-5301
US

V. Phone/Fax

Practice location:
  • Phone: 909-514-1958
  • Fax:
Mailing address:
  • Phone: 909-463-9279
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCICA02091019
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: