Healthcare Provider Details

I. General information

NPI: 1922518547
Provider Name (Legal Business Name): BRIGHTER PATH COUNSELING SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2017
Last Update Date: 10/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7828 HAVEN AVE STE 102
RANCHO CUCAMONGA CA
91730-3049
US

IV. Provider business mailing address

PO BOX 1176
FONTANA CA
92334-1176
US

V. Phone/Fax

Practice location:
  • Phone: 909-782-8382
  • Fax: 909-365-3576
Mailing address:
  • Phone: 909-782-8382
  • Fax: 909-365-3576

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number26127
License Number StateCA

VIII. Authorized Official

Name: JAVIER MARTIN PANAMENO CAMPOS
Title or Position: CHIEF EXECUTIVE OFFICER
Credential: LCSW
Phone: 909-782-8382