Healthcare Provider Details

I. General information

NPI: 1003726100
Provider Name (Legal Business Name): INLAND PSYCHIATRIC MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/10/2026
Last Update Date: 09/10/2026
Certification Date: 09/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

640 N MAIN ST
MANTECA CA
95336-3741
US

IV. Provider business mailing address

640 N MAIN ST
MANTECA CA
95336-3741
US

V. Phone/Fax

Practice location:
  • Phone: 209-900-4455
  • Fax: 209-399-4455
Mailing address:
  • Phone: 209-900-4455
  • Fax: 209-399-4455

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: ADMIN PROVIDER RELATION
Credential:
Phone: 909-289-4075