Healthcare Provider Details

I. General information

NPI: 1912372335
Provider Name (Legal Business Name): ILESE BUCHANAN MS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/10/2015
Last Update Date: 12/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 CENTRAL AVE STE 310
RIVERSIDE CA
92506-2181
US

IV. Provider business mailing address

PO BOX 52015
RIVERSIDE CA
92517-3015
US

V. Phone/Fax

Practice location:
  • Phone: 951-344-6428
  • Fax: 951-777-1318
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number103846
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: