Healthcare Provider Details

I. General information

NPI: 1780729905
Provider Name (Legal Business Name): RAQUEL SOLIS RUVALCABA M.S., LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/21/2007
Last Update Date: 02/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

934 N MOUNTAIN AVE STE C
UPLAND CA
91786-3659
US

IV. Provider business mailing address

934 N MOUNTAIN AVE # 0
UPLAND CA
91786-3659
US

V. Phone/Fax

Practice location:
  • Phone: 909-579-8100
  • Fax:
Mailing address:
  • Phone: 909-579-8100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number47542
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFC47622
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: