Provider Demographics
NPI:1407433428
Name:ANTOMMARCHI, CHALITA SHANAE
Entity Type:Individual
Prefix:
First Name:CHALITA
Middle Name:SHANAE
Last Name:ANTOMMARCHI
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 1:24898 SANITARIUM DR LINDSAY HALL BOX 106
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92350-0001
Mailing Address - Country:US
Mailing Address - Phone:703-401-3961
Mailing Address - Fax:
Practice Address - Street 1:101 N INDIAN HILL BLVD STE C2-202
Practice Address - Street 2:
Practice Address - City:CLAREMONT
Practice Address - State:CA
Practice Address - Zip Code:91711-4670
Practice Address - Country:US
Practice Address - Phone:909-521-8651
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-25
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist