Basic Information
| Provider Information | |||||||||
| NPI: | 1629590674 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VICUNA | ||||||||
| FirstName: | DOLORES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1569 N CLIFFORD AVE | ||||||||
| Address2: | |||||||||
| City: | RIALTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923763207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095187090 | ||||||||
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| Practice Location | |||||||||
| Address1: | 939 N D ST | ||||||||
| Address2: | |||||||||
| City: | SAN BERNARDINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 924103519 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9098896519 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2017 | ||||||||
| LastUpdateDate: | 07/14/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YM0800X | 5510 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.