Healthcare Provider Details

I. General information

NPI: 1134401672
Provider Name (Legal Business Name): KENDRA THEROITH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/11/2011
Last Update Date: 03/07/2023
Certification Date: 01/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2085 RUSTIN AVE # 4
RIVERSIDE CA
92507-2498
US

IV. Provider business mailing address

9431 HAVEN AVE STE 100
RANCHO CUCAMONGA CA
91730-5879
US

V. Phone/Fax

Practice location:
  • Phone: 951-955-8000
  • Fax:
Mailing address:
  • Phone: 909-282-2610
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number99414
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: