MEDICARE: TWELVE TWO INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1972435196
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TWELVE TWO INC.

Provider Business Mailing Address
First Line	:	13230 WINSLOW DR
Second Line	:
City	:	RANCHO CUCAMONGA
State	:	CA
Zip	:	91739-9271
Country	:	US
Telephone Number	:	909-477-1910
Fax Number	:

Provider Business Practice Location Address
First Line	:	207 N EUCLID AVE
Second Line	:
City	:	ONTARIO
State	:	CA
Zip	:	91762-3535
Country	:	US
Telephone Number	:	909-477-1910
Fax Number	:

Authorized Official
Title or Position	:	AUTHORIZED OFFICIAL
Name	:	ATHENA OBRIEN
Credential	:
Telephone Number	:	909-477-1910

Provider Enumeration Date	:	06/01/2026
Last Update Date	:	06/01/2026

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