Basic Information
| Provider Information | |||||||||
| NPI: | 1619414083 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CERVANTES | ||||||||
| FirstName: | DANNIELLE | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3713 | ||||||||
| Address2: | |||||||||
| City: | SAN DIMAS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917737713 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6266026049 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2008 N GAREY AVE | ||||||||
| Address2: | |||||||||
| City: | POMONA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917672722 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9096236131 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/24/2017 | ||||||||
| LastUpdateDate: | 02/03/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | APCC5802 | CA | N | Behavioral Health & Social Service Providers | Counselor | Professional | 106H00000X | 122768 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.