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NPI Code Detail

MEDICARE: LAURYN ANN SEALOCK

MEDICARE: LAURYN ANN SEALOCK
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1101YA0400XAddiction (Substance Use Disorder) Counselor
2167G00000XLicensed Psychiatric TechnicianPT42246CA

General Provider Information

NPI Number : 1558910935
Entity Type Code : Individual
Provider Name (Legal Business Name) : LAURYN ANN SEALOCK
Provider Business Mailing Address
First Line : 2085 RUSTIN AVE STE 1
Second Line :
City : RIVERSIDE
State : CA
Zip : 92507-2498
Country : US
Telephone Number : 951-955-7320
Fax Number :
Provider Business Practice Location Address
First Line : 15217 SAN BERNARDINO AVE
Second Line :
City : FONTANA
State : CA
Zip : 92335-5327
Country : US
Telephone Number : 951-643-2150
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 09/08/2019
Last Update Date : 02/14/2023

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