Healthcare Provider Details

I. General information

NPI: 1043133747
Provider Name (Legal Business Name): LLPMG COLTON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/31/2026
Last Update Date: 07/31/2026
Certification Date: 07/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1007 E COOLEY DR STE 109
COLTON CA
92324-3901
US

IV. Provider business mailing address

1007 E COOLEY DR STE 109
COLTON CA
92324-3901
US

V. Phone/Fax

Practice location:
  • Phone: 909-370-4700
  • Fax: 888-505-0620
Mailing address:
  • Phone: 909-370-4700
  • Fax: 888-505-0620

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: LIBERTY OLIVE MACIAS
Title or Position: CEO
Credential: NP
Phone: 909-900-6465