Healthcare Provider Details

I. General information

NPI: 1134714033
Provider Name (Legal Business Name): AMETHYST BEHAVIORAL HEALTH, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/03/2021
Last Update Date: 09/25/2025
Certification Date: 09/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

921 TRIBUNE ST
REDLANDS CA
92374-3422
US

IV. Provider business mailing address

320 E UNION AVE
REDLANDS CA
92374-3332
US

V. Phone/Fax

Practice location:
  • Phone: 909-809-7671
  • Fax:
Mailing address:
  • Phone: 909-809-7671
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: COLE OLIVER FRY
Title or Position: CEO
Credential:
Phone: 909-809-7671