Provider Demographics
NPI:1174923890
Name:BARNES, LAVONDE
Entity type:Individual
Prefix:
First Name:LAVONDE
Middle Name:
Last Name:BARNES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11815 SILVER LOOP
Mailing Address - Street 2:
Mailing Address - City:MIRA LOMA
Mailing Address - State:CA
Mailing Address - Zip Code:91752-4401
Mailing Address - Country:US
Mailing Address - Phone:951-817-8985
Mailing Address - Fax:
Practice Address - Street 1:637 E ALBERTONI ST
Practice Address - Street 2:200
Practice Address - City:CARSON
Practice Address - State:CA
Practice Address - Zip Code:90746-1539
Practice Address - Country:US
Practice Address - Phone:310-217-0616
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-29
Last Update Date:2014-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1386823789Medicaid