Healthcare Provider Details

I. General information

NPI: 1982823944
Provider Name (Legal Business Name): ALFREDA YVONNE BANTUM M.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/25/2007
Last Update Date: 03/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1505 W HIGHLAND AVE STE 17
SAN BERNARDINO CA
92411-1215
US

IV. Provider business mailing address

20426 TOBIRA LN
RIVERSIDE CA
92508-3030
US

V. Phone/Fax

Practice location:
  • Phone: 909-880-9130
  • Fax: 909-473-1918
Mailing address:
  • Phone: 951-756-9637
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number55644
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: