Healthcare Provider Details

I. General information

NPI: 1306767959
Provider Name (Legal Business Name): MISS CALISTA EADON BERUBE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2026
Last Update Date: 07/21/2026
Certification Date: 07/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2711 TEMESCAL AVE
NORCO CA
92860-2392
US

IV. Provider business mailing address

4175 BANDINI AVE
RIVERSIDE CA
92506-1168
US

V. Phone/Fax

Practice location:
  • Phone: 877-412-8031
  • Fax:
Mailing address:
  • Phone: 951-750-2687
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: