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General NPI Number Information
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NPI Number | 1346932555
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Entity Type | Organization
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Legal Business Name | KESEWA SAFE HAVEN
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Dates
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Enumeration Date | 05/24/2023
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Last Update Date | 05/24/2023
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Provider Practice Location Address
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Address Line | 229 S RIVERSIDE AVE
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City | RIALTO
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State | CA
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Zip | 92376-6467
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Country | US
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Telephone | 190-999-7586
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Fax |
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Provider Business Mailing Address
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Address Line | 520 W MESA AVE
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City | RIALTO
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State | CA
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Zip | 92376-3285
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Country | US
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Telephone | 909-997-5863
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Fax |
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Authorized Official
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Title or Position | LICENSED MARRIAGE THERAPIST
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Name | MR. NANA A BAMFO
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Credential | LMFT
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Telephone | 909-997-5863
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251B00000X
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Taxonomy Name | Case Management Agency
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 251K00000X
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Taxonomy Name | Public Health or Welfare Agency
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 251T00000X
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Taxonomy Name | PACE Provider Organization
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 252Y00000X
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Taxonomy Name | Early Intervention Provider Agency
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number |
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License Number State |
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Taxonomy #6
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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