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General NPI Number Information
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NPI Number | 1457626889
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Entity Type | Organization
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Legal Business Name | REALLIFEDREAMS
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Dates
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Enumeration Date | 03/19/2012
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Last Update Date | 03/19/2012
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Provider Practice Location Address
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Address Line | 14240 SAINT ANDREWS DR SUITE 101
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City | VICTORVILLE
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State | CA
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Zip | 92395-4308
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Country | US
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Telephone | 760-927-8896
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Fax | 866-382-9020
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Provider Business Mailing Address
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Address Line | 1554 BARTON RD # 114
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City | REDLANDS
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State | CA
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Zip | 92373-5457
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Country | US
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Telephone | 760-927-8896
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Fax | 866-382-9020
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Authorized Official
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Title or Position | PRESIDENT
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Name | MS. LYNN NICKENS
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Credential | LCSW
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Telephone | 760-927-8896
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 18158
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License Number State | CA
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