Healthcare Provider Details

I. General information

NPI: 1578494019
Provider Name (Legal Business Name): MTB WELLNESS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/26/2026
Last Update Date: 05/26/2026
Certification Date: 05/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6627 VIANZA PL
RANCHO CUCAMONGA CA
91701-9024
US

IV. Provider business mailing address

6627 VIANZA PL
RANCHO CUCAMONGA CA
91701-9024
US

V. Phone/Fax

Practice location:
  • Phone: 510-593-6257
  • Fax:
Mailing address:
  • Phone: 510-593-6257
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: KERRI AVERY
Title or Position: AUTHORIZED OFFICIAL
Credential: LCSW
Phone: 510-593-6257