Basic Information
| Provider Information | |||||||||
| NPI: | 1255740924 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ACOSTA | ||||||||
| FirstName: | ILEANA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14191 WOODLAND DR | ||||||||
| Address2: | |||||||||
| City: | FONTANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923372793 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 160 E HOLT AVE | ||||||||
| Address2: | B | ||||||||
| City: | POMONA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917675406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9096202521 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/07/2014 | ||||||||
| LastUpdateDate: | 04/14/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | IMF90654 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.