Healthcare Provider Details

I. General information

NPI: 1124955737
Provider Name (Legal Business Name): CLINICAL SOLUTIONS, LICENSED CLINICAL SOCIAL WORKER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/07/2026
Last Update Date: 05/07/2026
Certification Date: 05/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1519 WASHINGTON AVE
SAN JACINTO CA
92583-6075
US

IV. Provider business mailing address

315 E ESPLANADE AVE # 89
SAN JACINTO CA
92583-5102
US

V. Phone/Fax

Practice location:
  • Phone: 951-214-5071
  • Fax:
Mailing address:
  • Phone: 951-214-5071
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: KENYADA WAGONER
Title or Position: CO-OWNER
Credential: LCSW
Phone: 951-214-5071