Provider Demographics
NPI:1174653968
Name:CHAMPION, LATERRA WUNETTE (MSW)
Entity Type:Individual
Prefix:
First Name:LATERRA
Middle Name:WUNETTE
Last Name:CHAMPION
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18210 SANDY DR APT 203
Mailing Address - Street 2:
Mailing Address - City:CANYON COUNTRY
Mailing Address - State:CA
Mailing Address - Zip Code:91387-6063
Mailing Address - Country:US
Mailing Address - Phone:818-892-3423
Mailing Address - Fax:
Practice Address - Street 1:15317 RAYEN ST
Practice Address - Street 2:
Practice Address - City:NORTH HILLS
Practice Address - State:CA
Practice Address - Zip Code:91343-5117
Practice Address - Country:US
Practice Address - Phone:818-892-3423
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA18165OtherASSOCIATE SOCIAL WORKER