Basic Information
| Provider Information | |||||||||
| NPI: | 1275918146 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WORSHAM | ||||||||
| FirstName: | KELLISHIA | ||||||||
| MiddleName: | T | ||||||||
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| OtherLastName: | WORSHAM | ||||||||
| OtherFirstName: | KELLISHIA | ||||||||
| OtherMiddleName: | T | ||||||||
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| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 141 N ARROWHEAD AVE | ||||||||
| Address2: | |||||||||
| City: | SAN BERNARDINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 924081016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9099635355 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 222 N MOUNTAIN AVE | ||||||||
| Address2: | |||||||||
| City: | UPLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 91786 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9097270398 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2015 | ||||||||
| LastUpdateDate: | 06/18/2018 | ||||||||
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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 | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor | 171M00000X | CA | N | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.