Healthcare Provider Details

I. General information

NPI: 1275273583
Provider Name (Legal Business Name): ILLEEN JEAN SANCHEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/01/2022
Last Update Date: 10/08/2024
Certification Date: 10/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3125 MYERS ST
RIVERSIDE CA
92503-5527
US

IV. Provider business mailing address

2085 RUSTIN AVE
RIVERSIDE CA
92507-2498
US

V. Phone/Fax

Practice location:
  • Phone: 951-358-4840
  • Fax:
Mailing address:
  • Phone: 951-955-8000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberMPSS-QODYVB
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberR1478700822
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: