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General NPI Number Information
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NPI Number | 1104384635
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Entity Type | Individual
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Provider Name | CHANNING RENEE LACKEY
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Gender | Female
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Dates
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Enumeration Date | 03/04/2019
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Last Update Date | 08/27/2025
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Provider Practice Location Address
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Address Line | 222 W 6TH ST
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City | CORONA
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State | CA
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Zip | 92882-3301
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Country | US
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Telephone | 888-682-6282
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Fax |
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Provider Business Mailing Address
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Address Line | 13267 ROSWELL AVE
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City | CHINO
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State | CA
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Zip | 91710-4771
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Country | US
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Telephone | 909-680-8019
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number |
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License Number State |
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