Healthcare Provider Details

I. General information

NPI: 1639925464
Provider Name (Legal Business Name): MAPLE LEAF COUNSELING, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2024
Last Update Date: 04/30/2024
Certification Date: 04/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 N INDIAN HILL BLVD
CLAREMONT CA
91711-4614
US

IV. Provider business mailing address

1035 W 14TH ST
UPLAND CA
91786-2678
US

V. Phone/Fax

Practice location:
  • Phone: 626-818-8327
  • Fax:
Mailing address:
  • Phone: 626-818-8327
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name: ANTOINETTE IBRAHIMI
Title or Position: OWNER
Credential: PSY.D.
Phone: 626-818-8327