Healthcare Provider Details

I. General information

NPI: 1093020836
Provider Name (Legal Business Name): ART IMLA LMFT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2010
Last Update Date: 02/04/2020
Certification Date: 02/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 W HOSPITALITY LN STE 208
SAN BERNARDINO CA
92408-3211
US

IV. Provider business mailing address

8363 FALL CREEK DR
EASTVALE CA
92880-3914
US

V. Phone/Fax

Practice location:
  • Phone: 909-963-5377
  • Fax:
Mailing address:
  • Phone: 818-359-2425
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number62994
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: