Healthcare Provider Details

I. General information

NPI: 1992987242
Provider Name (Legal Business Name): DOLORES MARIA MAST LCSW 63286
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MS. DOLORES MARIA MARTINEZ

II. Dates (important events)

Enumeration Date: 11/28/2007
Last Update Date: 04/28/2021
Certification Date: 04/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17830 ARROW BLVD
FONTANA CA
92335-4037
US

IV. Provider business mailing address

17830 ARROW BLVD
FONTANA CA
92335-4037
US

V. Phone/Fax

Practice location:
  • Phone: 909-356-6451
  • Fax:
Mailing address:
  • Phone: 909-356-6415
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW 63286
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: