Healthcare Provider Details

I. General information

NPI: 1346845013
Provider Name (Legal Business Name): INLAND PSYCHIATRIC MEDICAL GROUP, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2020
Last Update Date: 01/07/2021
Certification Date: 01/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

81709 DR CARREON BLVD # B-4
INDIO CA
92201-5509
US

IV. Provider business mailing address

81709 DR CARREON BLVD STE C1
INDIO CA
92201-5577
US

V. Phone/Fax

Practice location:
  • Phone: 760-330-5161
  • Fax: 760-407-6862
Mailing address:
  • Phone: 760-330-5161
  • Fax: 760-407-6862

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: AMBER GUTIERREZ
Title or Position: PROVIDER RELATIONS
Credential:
Phone: 909-289-4075