Healthcare Provider Details

I. General information

NPI: 1619544988
Provider Name (Legal Business Name): PRUDENT TELEPSYCHIATRY CARE A MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2021
Last Update Date: 05/10/2024
Certification Date: 04/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8880 BENSON AVE STE 125
MONTCLAIR CA
91763-1661
US

IV. Provider business mailing address

8880 BENSON AVE STE 125
MONTCLAIR CA
91763-1661
US

V. Phone/Fax

Practice location:
  • Phone: 323-632-5868
  • Fax: 866-214-8786
Mailing address:
  • Phone: 866-214-7214
  • Fax: 866-214-8786

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: FELISTA ANUGOM
Title or Position: PRESIDENT
Credential: PMHNP, FNP
Phone: 866-214-7214