Provider Demographics
NPI:1003146416
Name:DARRETT, GOLEANIA CHERIC
Entity Type:Individual
Prefix:
First Name:GOLEANIA
Middle Name:CHERIC
Last Name:DARRETT
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 1:1304 SANTA YNEZ AVE APT 322
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91913-1485
Mailing Address - Country:US
Mailing Address - Phone:818-626-0631
Mailing Address - Fax:
Practice Address - Street 1:2940 INLAND EMPIRE BLVD
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91764-4898
Practice Address - Country:US
Practice Address - Phone:909-458-1371
Practice Address - Fax:909-466-4820
Is Sole Proprietor?:No
Enumeration Date:2010-01-06
Last Update Date:2018-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA19685600Medicaid
CACMM70956FMedicaid