Healthcare Provider Details

I. General information

NPI: 1063101715
Provider Name (Legal Business Name): LOCKED IN CEA INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2023
Last Update Date: 05/08/2023
Certification Date: 05/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4937 SIERRA VISTA AVE
RIVERSIDE CA
92505
US

IV. Provider business mailing address

P.O. BOX 70665
RIVERSIDE CA
92513
US

V. Phone/Fax

Practice location:
  • Phone: 951-394-1656
  • Fax:
Mailing address:
  • Phone: 951-394-1656
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: MISS DEANNE M KNIPSCHILD
Title or Position: CEO
Credential: MA
Phone: 951-394-1656