Healthcare Provider Details

I. General information

NPI: 1487463444
Provider Name (Legal Business Name): MS. ALEXANDRIA CAPETILLO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2025
Last Update Date: 10/03/2025
Certification Date: 10/03/2025
Deactivation Date: 01/06/2025
Reactivation Date: 02/25/2025

III. Provider practice location address

390 N EUCLID AVE
UPLAND CA
91786-4763
US

IV. Provider business mailing address

852 N PALM AVE APT A
UPLAND CA
91786-3882
US

V. Phone/Fax

Practice location:
  • Phone: 909-985-1864
  • Fax:
Mailing address:
  • Phone: 909-365-8273
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number17090
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: