Healthcare Provider Details

I. General information

NPI: 1508798612
Provider Name (Legal Business Name): GINA M WINFREY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/02/2026
Last Update Date: 06/03/2026
Certification Date: 06/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11799 SEBASTIAN WAY #103
RANCHO CUCAMONGA CA
91730
US

IV. Provider business mailing address

4731 N STODDARD AVE
SAN BERNARDINO CA
92407-3635
US

V. Phone/Fax

Practice location:
  • Phone: 909-276-0877
  • Fax:
Mailing address:
  • Phone: 909-276-0877
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number10650000X
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: