Healthcare Provider Details

I. General information

NPI: 1497339394
Provider Name (Legal Business Name): VIVIAN CASSANDRA HURTADO AMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/07/2021
Last Update Date: 09/02/2022
Certification Date: 09/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 E GILBERT ST
SAN BERNARDINO CA
92415-3258
US

IV. Provider business mailing address

820 E GILBERT ST
SAN BERNARDINO CA
92415-0928
US

V. Phone/Fax

Practice location:
  • Phone: 909-387-7200
  • Fax: 909-387-7717
Mailing address:
  • Phone: 909-387-7200
  • Fax: 909-387-7717

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberAMFT134018
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: