Healthcare Provider Details

I. General information

NPI: 1801604277
Provider Name (Legal Business Name): GREAT MIND COUNSELING AND SKILL BUILDING CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/18/2024
Last Update Date: 02/14/2025
Certification Date: 02/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

441 MACKAY DR
SAN BERNARDINO CA
92408-3230
US

IV. Provider business mailing address

441 MACKAY DR
SAN BERNARDINO CA
92408-3230
US

V. Phone/Fax

Practice location:
  • Phone: 702-589-0701
  • Fax:
Mailing address:
  • Phone: 702-589-0701
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: MAIMOUNA CANTRALL
Title or Position: BUSINESS OWNER
Credential:
Phone: 702-589-0701