Healthcare Provider Details

I. General information

NPI: 1790616332
Provider Name (Legal Business Name): TEGAN SAMANTHA ERIN BELLAMY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/25/2026
Last Update Date: 05/25/2026
Certification Date: 05/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX 5090
FONTANA CA
92334-5090
US

IV. Provider business mailing address

PO BOX 5090
FONTANA CA
92334-5090
US

V. Phone/Fax

Practice location:
  • Phone: 626-695-8400
  • Fax:
Mailing address:
  • Phone: 626-695-8400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number13596
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number157218
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: