Basic Information
| Provider Information | |||||||||
| NPI: | 1023441011 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PAGE | ||||||||
| FirstName: | HEIDIE | ||||||||
| MiddleName: | KAY | ||||||||
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| Credential: | MSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 850 E FOOTHILL BLVD # BCD | ||||||||
| Address2: | |||||||||
| City: | RIALTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923765230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9094214683 | ||||||||
| FaxNumber: | 9094219466 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 N PEPPER AVE | ||||||||
| Address2: | |||||||||
| City: | COLTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923241801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095802141 | ||||||||
| FaxNumber: | 9095802866 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/14/2013 | ||||||||
| LastUpdateDate: | 06/22/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | CA | N | Behavioral Health & Social Service Providers | Counselor | 101Y00000X | N | Behavioral Health & Social Service Providers | Counselor | 1041C0700X | LCSW87883 | CA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.