Healthcare Provider Details

I. General information

NPI: 1619712726
Provider Name (Legal Business Name): WELLNESS RANCH EQUINE ASSISTED THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/28/2024
Last Update Date: 06/28/2024
Certification Date: 06/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9721 BRILLIANT LN
RANCHO CUCAMONGA CA
91737-2920
US

IV. Provider business mailing address

9721 BRILLIANT LN
RANCHO CUCAMONGA CA
91737-2920
US

V. Phone/Fax

Practice location:
  • Phone: 909-710-3055
  • Fax:
Mailing address:
  • Phone: 909-710-3055
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: ANGELICA D MANZO
Title or Position: EXECUTIVE DIRECTOR
Credential: MA, LPCC
Phone: 909-710-3055