Healthcare Provider Details

I. General information

NPI: 1245055029
Provider Name (Legal Business Name): SIERRA PSYCHOLOGICAL SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/18/2024
Last Update Date: 11/18/2024
Certification Date: 11/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 N MOUNTAIN AVE STE C205B
UPLAND CA
91786-4315
US

IV. Provider business mailing address

154A W FOOTHILL BLVD # 421
UPLAND CA
91786-3847
US

V. Phone/Fax

Practice location:
  • Phone: 909-758-2175
  • Fax:
Mailing address:
  • Phone: 909-758-2175
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: MARIA MORENO
Title or Position: ADMINISTRATOR
Credential: EDD
Phone: 909-758-2175