MEDICARE: MR. RAIED ESA SALEM IMFT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	IMF78672	CA
2	106H00000X	Marriage & Family Therapist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	IMF78672	OTHER	CA	BOARD OF BEHAVIORAL SCIENCES

General Provider Information

NPI Number	:	1285031799
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. RAIED ESA SALEM IMFT

Provider Business Mailing Address
First Line	:	7828 HAVEN AVE # 207
Second Line	:
City	:	RANCHO CUCAMONGA
State	:	CA
Zip	:	91730-3049
Country	:	US
Telephone Number	:	909-713-4777
Fax Number	:

Provider Business Practice Location Address
First Line	:	7828 HAVEN AVE # 207
Second Line	:
City	:	RANCHO CUCAMONGA
State	:	CA
Zip	:	91730-3049
Country	:	US
Telephone Number	:	909-713-4777
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/26/2014
Last Update Date	:	08/05/2015

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