Healthcare Provider Details

I. General information

NPI: 1144046475
Provider Name (Legal Business Name): RADIANT PATH THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/03/2024
Last Update Date: 01/02/2026
Certification Date: 01/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12139 MOUNT VERNON AVE STE 210
GRAND TERRACE CA
92313-5562
US

IV. Provider business mailing address

12139 MOUNT VERNON AVE STE 210
GRAND TERRACE CA
92313-5562
US

V. Phone/Fax

Practice location:
  • Phone: 951-205-2949
  • Fax:
Mailing address:
  • Phone: 951-205-2949
  • Fax: 866-365-2227

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: LANDON EHTESHAMZADEH
Title or Position: CO-OWNER
Credential:
Phone: 951-205-2949