Healthcare Provider Details

I. General information

NPI: 1780296764
Provider Name (Legal Business Name): CASEY ANNE GIDCUMB
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/20/2020
Last Update Date: 06/03/2025
Certification Date: 06/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

290 N D ST STE 700
SAN BERNARDINO CA
92401-1705
US

IV. Provider business mailing address

290 N D ST STE 700
SAN BERNARDINO CA
92401-1705
US

V. Phone/Fax

Practice location:
  • Phone: 909-963-5355
  • Fax:
Mailing address:
  • Phone: 909-963-5355
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number16474
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: