Healthcare Provider Details

I. General information

NPI: 1457186017
Provider Name (Legal Business Name): SHYTEARIA THURMAN PPS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/04/2024
Last Update Date: 09/11/2024
Certification Date: 09/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5685 SAN BERNARDINO ST
MONTCLAIR CA
91763-2941
US

IV. Provider business mailing address

250 N COLLEGE PARK DR APT B14
UPLAND CA
91786-9452
US

V. Phone/Fax

Practice location:
  • Phone: 909-984-9556
  • Fax:
Mailing address:
  • Phone: 909-581-2700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number240093670
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: