Healthcare Provider Details

I. General information

NPI: 1487205506
Provider Name (Legal Business Name): INLAND PSYCHIATRIC MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2019
Last Update Date: 12/17/2019
Certification Date: 12/17/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4049 BROCKTON AVE
RIVERSIDE CA
92501-3440
US

IV. Provider business mailing address

1809 W REDLANDS BLVD
REDLANDS CA
92373-8054
US

V. Phone/Fax

Practice location:
  • Phone: 951-300-8124
  • Fax: 951-262-7702
Mailing address:
  • Phone: 909-335-3026
  • Fax: 909-335-3167

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: AMBER GUTIERREZ
Title or Position: CREDENTIALING
Credential:
Phone: 909-289-4075