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General NPI Number Information
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NPI Number | 1346790524
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Entity Type | Organization
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Legal Business Name | WISDOM TREE COUNSELING
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Dates
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Enumeration Date | 10/11/2016
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Last Update Date | 10/11/2016
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Provider Practice Location Address
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Address Line | 10601 CIVIC CENTER DR SUITE 100-M
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City | RANCHO CUCAMONGA
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State | CA
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Zip | 91730-3878
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Country | US
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Telephone | 909-291-9349
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Fax |
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Provider Business Mailing Address
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Address Line | 10601 CIVIC CENTER DR
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City | RANCHO CUCAMONGA
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State | CA
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Zip | 91730-3878
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Country | US
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Telephone | 909-291-9349
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | JERALEEN M PETERSON
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Credential | LCSW
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Telephone | 909-291-9349
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | LCS28561
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License Number State | CA
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