Healthcare Provider Details

I. General information

NPI: 1972096295
Provider Name (Legal Business Name): MENTAL WELLNESS PARTNERS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2018
Last Update Date: 06/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 N MOUNTAIN AVE STE 215
UPLAND CA
91786-4163
US

IV. Provider business mailing address

14617 WESTFIELD AVE
CHINO CA
91710-1303
US

V. Phone/Fax

Practice location:
  • Phone: 909-920-3171
  • Fax:
Mailing address:
  • Phone: 909-203-3523
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number20A12214
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberNP16510
License Number StateCA

VIII. Authorized Official

Name: MR. PERCIVAL JOHN BALDRIAS
Title or Position: NURSE PRACTITIONER/CFO
Credential: NP
Phone: 909-920-3171