=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073960795
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MAKAYLA CONDIE LCPC, CMHC, LPCC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/23/2016
-----------------------------------------------------
Last Update Date | 09/25/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3355 N WHITE AVE #7192
-----------------------------------------------------
City | LA VERNE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91750-7192
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-219-0425
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3355 N WHITE AVE #7192
-----------------------------------------------------
City | LA VERNE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91750-7192
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-219-0425
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 13852
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 11697949-6004
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | LCPC-7003
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | LPC - 6171
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------