Healthcare Provider Details

I. General information

NPI: 1306502869
Provider Name (Legal Business Name): MELISSA V CERVANTES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2021
Last Update Date: 08/04/2026
Certification Date: 08/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

239 W 9TH ST
UPLAND CA
91786-5979
US

IV. Provider business mailing address

239 W 9TH ST
UPLAND CA
91786-5979
US

V. Phone/Fax

Practice location:
  • Phone: 909-981-6121
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number17559
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: