Healthcare Provider Details

I. General information

NPI: 1619788007
Provider Name (Legal Business Name): NEYMI MIREYA MEMBRENO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/15/2025
Last Update Date: 09/01/2026
Certification Date: 09/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 E FOOTHILL BLVD
RIALTO CA
92376-5230
US

IV. Provider business mailing address

850 E FOOTHILL BLVD
RIALTO CA
92376-5230
US

V. Phone/Fax

Practice location:
  • Phone: 909-421-9472
  • Fax: 909-421-9392
Mailing address:
  • Phone: 562-852-3491
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number163545
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: