Healthcare Provider Details

I. General information

NPI: 1417795782
Provider Name (Legal Business Name): BURGOS PSYCHOLOGICAL SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2024
Last Update Date: 07/19/2024
Certification Date: 07/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16425 EL REVINO DR
FONTANA CA
92336-5843
US

IV. Provider business mailing address

PO BOX 1025
ONTARIO CA
91762-0025
US

V. Phone/Fax

Practice location:
  • Phone: 909-451-9904
  • Fax: 909-310-9763
Mailing address:
  • Phone: 909-451-9904
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: YVONNE BURGOS
Title or Position: OWNER
Credential:
Phone: 909-451-9904