Provider Demographics
NPI:1558071860
Name:PRENTICE, RONALD
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:
Last Name:PRENTICE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:604 S PRAIRIE PL
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92807-4638
Mailing Address - Country:US
Mailing Address - Phone:714-356-1600
Mailing Address - Fax:
Practice Address - Street 1:505 S VILLA REAL STE 117
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92807-3441
Practice Address - Country:US
Practice Address - Phone:714-356-1600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-28
Last Update Date:2022-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA28664106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist