Healthcare Provider Details

I. General information

NPI: 1104603315
Provider Name (Legal Business Name): MIND CABANA FAMILY COUNSELING INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/11/2023
Last Update Date: 09/11/2023
Certification Date: 09/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7252 ARCHIBALD AVE # 1027
RANCHO CUCAMONGA CA
91701-5017
US

IV. Provider business mailing address

7252 ARCHIBALD AVE # 1027
RANCHO CUCAMONGA CA
91701-5017
US

V. Phone/Fax

Practice location:
  • Phone: 323-902-1089
  • Fax:
Mailing address:
  • Phone: 323-902-1089
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER MORRIS
Title or Position: EXECUTIVE DIRECTOR
Credential: LMFT
Phone: 909-534-7530