Healthcare Provider Details

I. General information

NPI: 1629984570
Provider Name (Legal Business Name): MS. DESTINY NICOLE WILFORD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/20/2026
Last Update Date: 08/21/2026
Certification Date: 08/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 N PEPPER AVE
COLTON CA
92324-1801
US

IV. Provider business mailing address

26460 REDLANDS BLVD APT 14
REDLANDS CA
92373-6208
US

V. Phone/Fax

Practice location:
  • Phone: 909-580-1800
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code167G00000X
TaxonomyLicensed Psychiatric Technician
License Number41822
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: