Healthcare Provider Details

I. General information

NPI: 1558910935
Provider Name (Legal Business Name): LAURYN ANN SEALOCK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/08/2019
Last Update Date: 02/14/2023
Certification Date: 02/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15217 SAN BERNARDINO AVE
FONTANA CA
92335-5327
US

IV. Provider business mailing address

2085 RUSTIN AVE STE 1
RIVERSIDE CA
92507-2498
US

V. Phone/Fax

Practice location:
  • Phone: 951-643-2150
  • Fax:
Mailing address:
  • Phone: 951-955-7320
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code167G00000X
TaxonomyLicensed Psychiatric Technician
License NumberPT42246
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: