Provider Demographics
NPI:1578759098
Name:NEVAREZ, ANTENIQUE JITAE (LMFT)
Entity Type:Individual
Prefix:MRS
First Name:ANTENIQUE
Middle Name:JITAE
Last Name:NEVAREZ
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:MS
Other - First Name:ANTENIQUE
Other - Middle Name:JI TAE
Other - Last Name:CHAMBERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMFT
Mailing Address - Street 1:303 E VANDERBILT WAY
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92415-0026
Mailing Address - Country:US
Mailing Address - Phone:909-386-8229
Mailing Address - Fax:909-890-0574
Practice Address - Street 1:303 E VANDERBILT WAY
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92415-0026
Practice Address - Country:US
Practice Address - Phone:909-386-8229
Practice Address - Fax:909-890-0574
Is Sole Proprietor?:No
Enumeration Date:2007-09-18
Last Update Date:2016-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA84634106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist