Provider Demographics
NPI:1821668468
Name:CHANDLER, CITLALY VERNETTA (AA)
Entity Type:Individual
Prefix:
First Name:CITLALY
Middle Name:VERNETTA
Last Name:CHANDLER
Suffix:
Gender:F
Credentials:AA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5287 MANHART CIR
Mailing Address - Street 2:
Mailing Address - City:JURUPA VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92509-6883
Mailing Address - Country:US
Mailing Address - Phone:951-961-5419
Mailing Address - Fax:
Practice Address - Street 1:1650 SPRUCE ST
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507-7402
Practice Address - Country:US
Practice Address - Phone:951-961-5419
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-27
Last Update Date:2021-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician