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General NPI Number Information
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NPI Number | 1649085507
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Entity Type | Organization
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Legal Business Name | RESTORE MENTAL WELLNESS, LICENSED CLINICAL SOCIAL WORKER, INC
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Dates
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Enumeration Date | 02/10/2025
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Last Update Date | 02/10/2025
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Provider Practice Location Address
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Address Line | 22521 SCARLET SAGE WAY
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City | MORENO VALLEY
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State | CA
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Zip | 92557-5921
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Country | US
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Telephone | 562-556-1312
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Fax |
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Provider Business Mailing Address
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Address Line | 13502 WHITTIER BLVD # H232
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City | WHITTIER
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State | CA
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Zip | 90605-1945
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Country | US
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Telephone | 562-556-1312
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | MRS. DIANITZA MEDINA
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Credential | LCSW
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Telephone | 562-556-1312
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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 |
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License Number State |
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