Basic Information
| Provider Information | |||||||||
| NPI: | 1497937023 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FITE | ||||||||
| FirstName: | BRENT | ||||||||
| MiddleName: | DONALD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11 TENNESSEE ST APT 213 | ||||||||
| Address2: | |||||||||
| City: | REDLANDS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923735426 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9093889191 | ||||||||
| FaxNumber: | 9093889195 | ||||||||
| Practice Location | |||||||||
| Address1: | 2080 S E ST | ||||||||
| Address2: | |||||||||
| City: | SAN BERNARDINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 924082706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9093889191 | ||||||||
| FaxNumber: | 9093889195 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/05/2007 | ||||||||
| LastUpdateDate: | 12/05/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 1124100383 | 01 | CA | BEHAVIOR HEALTH PROVIDER | OTHER |