Healthcare Provider Details

I. General information

NPI: 1497678791
Provider Name (Legal Business Name): IMAGO DEI COLLECTIVE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2026
Last Update Date: 08/03/2026
Certification Date: 07/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35210 AVENUE A
YUCAIPA CA
92399-4325
US

IV. Provider business mailing address

35210 AVENUE
YUCAIPA CA
92399
US

V. Phone/Fax

Practice location:
  • Phone: 909-769-6593
  • Fax: 909-253-0199
Mailing address:
  • Phone: 909-769-6593
  • Fax: 909-253-0199

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: CANDACE DEESE
Title or Position: CEO/PRESIDENT
Credential: LMFT
Phone: 909-769-6593