Healthcare Provider Details

I. General information

NPI: 1932687613
Provider Name (Legal Business Name): TANISHA SIMPSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/03/2018
Last Update Date: 09/11/2026
Certification Date: 09/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11875 PIGEON PASS RD STE B13
MORENO VALLEY CA
92557-6044
US

IV. Provider business mailing address

3200 E GUASTI RD STE 100
ONTARIO CA
91761-8661
US

V. Phone/Fax

Practice location:
  • Phone: 951-801-9387
  • Fax:
Mailing address:
  • Phone: 310-686-3884
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number116984
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: