Healthcare Provider Details

I. General information

NPI: 1215185251
Provider Name (Legal Business Name): MERCEDES G ITRIAGO PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/03/2008
Last Update Date: 06/20/2023
Certification Date: 06/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

572 N ARROWHEAD AVE STE 200
SAN BERNARDINO CA
92401-1251
US

IV. Provider business mailing address

572 N ARROWHEAD AVE STE 200
SAN BERNARDINO CA
92401-1251
US

V. Phone/Fax

Practice location:
  • Phone: 909-266-2739
  • Fax:
Mailing address:
  • Phone: 909-266-2739
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY28045
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: