Healthcare Provider Details

I. General information

NPI: 1760075634
Provider Name (Legal Business Name): CENTER FOR BLACK WELLNESS & EXCELLENCE SOCIAL PURPOSE CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/11/2021
Last Update Date: 02/11/2021
Certification Date: 01/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

473 E. CARNEGIE DR. SUITE 200
SAN BERNARDINO CA
92408
US

IV. Provider business mailing address

473 E CARNEGIE DRIVE SUITE 200
SAN BERNARDINO CA
92408
US

V. Phone/Fax

Practice location:
  • Phone: 909-505-0557
  • Fax:
Mailing address:
  • Phone: 909-505-0557
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name: SHARMELLE PARKER
Title or Position: CEO & PRESIDENT
Credential: MSW
Phone: 909-505-0557