Healthcare Provider Details

I. General information

NPI: 1770438822
Provider Name (Legal Business Name): RADIANT PATH MARRIAGE AND FAMILY THERAPY, A PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/03/2026
Last Update Date: 06/10/2026
Certification Date: 06/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

308 W STATE ST STE 3D
REDLANDS CA
92373-4653
US

IV. Provider business mailing address

308 W STATE ST STE 3D
REDLANDS CA
92373-4653
US

V. Phone/Fax

Practice location:
  • Phone: 909-577-1124
  • Fax:
Mailing address:
  • Phone: 909-577-1124
  • 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 Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: LANDON EHTESHAMZADEH
Title or Position: VICE PRESIDENT
Credential:
Phone: 951-205-2949