Healthcare Provider Details

I. General information

NPI: 1679320832
Provider Name (Legal Business Name): HUMANITY CENTER 4 CHANGE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2024
Last Update Date: 12/28/2024
Certification Date: 12/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9791 ARROW RTE
RANCHO CUCAMONGA CA
91730-3602
US

IV. Provider business mailing address

5001 W FLORIDA AVE SPC 688
HEMET CA
92545-3822
US

V. Phone/Fax

Practice location:
  • Phone: 951-531-6785
  • Fax:
Mailing address:
  • Phone: 951-531-6785
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. TERESA ETHRIDGE
Title or Position: PSYCHOLOGIST/INTERN
Credential: DR.
Phone: 951-531-6785