Healthcare Provider Details

I. General information

NPI: 1760195838
Provider Name (Legal Business Name): LA VID TREE OF LIFE MARRIAGE AND FAMILY THERAPY SERVICES INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2023
Last Update Date: 01/03/2023
Certification Date: 01/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8273 WHITE OAK AVE # B
RANCHO CUCAMONGA CA
91730-7671
US

IV. Provider business mailing address

523 W ELM ST
ONTARIO CA
91762-5712
US

V. Phone/Fax

Practice location:
  • Phone: 840-207-9256
  • Fax:
Mailing address:
  • Phone: 909-631-5768
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State

VIII. Authorized Official

Name: ARLYN XIOMARA MENDOZA
Title or Position: PRESIDENT
Credential: LMFT
Phone: 909-631-5768