Basic Information
| Provider Information | |||||||||
| NPI: | 1730636697 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PASSAS | ||||||||
| FirstName: | ERNESTINE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 11874 CORNELL LN | ||||||||
| Address2: | |||||||||
| City: | YUCAIPA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923993905 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7023051277 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 790 VIA LATA | ||||||||
| Address2: | |||||||||
| City: | COLTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923243978 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9094330445 | ||||||||
| FaxNumber: | 9094330556 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/07/2016 | ||||||||
| LastUpdateDate: | 12/09/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | CA | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 1041C0700X | 105022 | CA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.