Healthcare Provider Details

I. General information

NPI: 1710882774
Provider Name (Legal Business Name): IDA SWEETWATER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2026
Last Update Date: 10/10/2026
Certification Date: 10/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1404 W COVINA BLVD
SAN DIMAS CA
91773-3208
US

IV. Provider business mailing address

98 W SANDRA AVE
ARCADIA CA
91007-8522
US

V. Phone/Fax

Practice location:
  • Phone: 909-592-2282
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number164662
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: