Healthcare Provider Details

I. General information

NPI: 1619505088
Provider Name (Legal Business Name): EDGAR J CERVANTES LMFT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/31/2020
Last Update Date: 11/09/2021
Certification Date: 11/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6800 INDIANA AVE STE 130
RIVERSIDE CA
92506-4266
US

IV. Provider business mailing address

9825 MAGNOLIA AVE STE B
RIVERSIDE CA
92503-3565
US

V. Phone/Fax

Practice location:
  • Phone: 323-273-6886
  • Fax:
Mailing address:
  • Phone: 951-509-2499
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number109185
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: