Healthcare Provider Details

I. General information

NPI: 1720524168
Provider Name (Legal Business Name): BRIANNA DESANTIAGO LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/09/2017
Last Update Date: 02/01/2024
Certification Date: 02/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19322 JESSE LN STE 200
RIVERSIDE CA
92508-5072
US

IV. Provider business mailing address

15643 SOUTHWIND AVE
FONTANA CA
92336-4158
US

V. Phone/Fax

Practice location:
  • Phone: 951-387-4040
  • Fax:
Mailing address:
  • Phone: 909-904-1256
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number140235
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: