Healthcare Provider Details

I. General information

NPI: 1124234224
Provider Name (Legal Business Name): NIDIA YAMILETH CANELLO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2007
Last Update Date: 04/13/2021
Certification Date: 04/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2025 N D ST
SAN BERNARDINO CA
92405-3913
US

IV. Provider business mailing address

9238 MONTE VISTA ST
ALTA LOMA CA
91701-4839
US

V. Phone/Fax

Practice location:
  • Phone: 909-475-8793
  • Fax:
Mailing address:
  • Phone: 909-466-9220
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: