Provider Demographics
NPI:1497252902
Name:NEAL, IESHIA SHADARA
Entity Type:Individual
Prefix:
First Name:IESHIA
Middle Name:SHADARA
Last Name:NEAL
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 1:45417 30TH ST W APT 105
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93536-6179
Mailing Address - Country:US
Mailing Address - Phone:661-450-7776
Mailing Address - Fax:
Practice Address - Street 1:23502 LYONS AVE
Practice Address - Street 2:STE 304
Practice Address - City:VALENCIA
Practice Address - State:CA
Practice Address - Zip Code:91321
Practice Address - Country:US
Practice Address - Phone:661-702-0166
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-11
Last Update Date:2018-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARBT-18-50787106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician