Healthcare Provider Details

I. General information

NPI: 1497026538
Provider Name (Legal Business Name): ALICIA TAVERNER LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/20/2012
Last Update Date: 01/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 909-257-4638
  • Fax:
Mailing address:
  • Phone: 909-257-4638
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number55591
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: