Healthcare Provider Details

I. General information

NPI: 1043763089
Provider Name (Legal Business Name): BETHANY VIERRA BARBOZA MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2016
Last Update Date: 09/26/2024
Certification Date: 09/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17830 ARROW BLVD
FONTANA CA
92335-4037
US

IV. Provider business mailing address

820 E GILBERT ST
SAN BERNARDINO CA
92415-0928
US

V. Phone/Fax

Practice location:
  • Phone: 909-356-6486
  • Fax: 909-386-8520
Mailing address:
  • Phone: 909-387-7200
  • Fax: 909-386-8520

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number122656
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: