Basic Information
| Provider Information | |||||||||
| NPI: | 1871931717 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SAN BERNARDINO COUNTY SUPERINTENDENT OF SCHOOLS | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | DESERT MOUNTAIN CHILDREN'S CENTER | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 17800 US HIGHWAY 18 | ||||||||
| Address2: | |||||||||
| City: | APPLE VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923071221 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7602426336 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 58967 BUSINESS CENTER DR | ||||||||
| Address2: | SUITES C & D | ||||||||
| City: | YUCCA VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922847300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7603653022 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2013 | ||||||||
| LastUpdateDate: | 06/02/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LLAMAS | ||||||||
| AuthorizedOfficialFirstName: | LINDA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7609553606 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SAN BERNARDINO COUNTY SUPERINTENDENT OF SCHOOLS | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | LMFT | ||||||||
| NPICertificationDate: | 06/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | SS3610363 | CA | Y | Agencies | Community/Behavioral Health |
No ID Information.