Provider Demographics
NPI:1407405871
Name:DETRIE, RACHEL JUNE
Entity Type:Individual
Prefix:
First Name:RACHEL
Middle Name:JUNE
Last Name:DETRIE
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 1:1911 WILLIAMS DR STE 210
Mailing Address - Street 2:
Mailing Address - City:OXNARD
Mailing Address - State:CA
Mailing Address - Zip Code:93036-2612
Mailing Address - Country:US
Mailing Address - Phone:805-981-6830
Mailing Address - Fax:
Practice Address - Street 1:1911 WILLIAMS DR STE 210
Practice Address - Street 2:
Practice Address - City:OXNARD
Practice Address - State:CA
Practice Address - Zip Code:93036-2612
Practice Address - Country:US
Practice Address - Phone:805-981-6830
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-09
Last Update Date:2023-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103T00000X
MI6301018024103T00000X
CA34051103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist