Healthcare Provider Details

I. General information

NPI: 1780848408
Provider Name (Legal Business Name): DUSTIN JOHN VANDER HAAR MFT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2008
Last Update Date: 10/30/2020
Certification Date: 10/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6700 INDIANA AVE
RIVERSIDE CA
92506-4290
US

IV. Provider business mailing address

7621 CYPRUS STREET
SAN DIMAS CA
91773
US

V. Phone/Fax

Practice location:
  • Phone: 909-599-1227
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFT51930
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: