Healthcare Provider Details

I. General information

NPI: 1104796333
Provider Name (Legal Business Name): TLW MARRIAGE & FAMILY THERAPY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/11/2025
Last Update Date: 12/29/2025
Certification Date: 12/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4344 LATHAM ST STE 110
RIVERSIDE CA
92501-1773
US

IV. Provider business mailing address

11799 SEBASTIAN WAY STE 103
RANCHO CUCAMONGA CA
91730-0708
US

V. Phone/Fax

Practice location:
  • Phone: 909-684-1966
  • Fax:
Mailing address:
  • Phone: 909-684-1966
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name: TENNILLE LINDSEYWRIGHT
Title or Position: PRESIDENT
Credential: LMFT
Phone: 909-684-1966