Basic Information
| Provider Information | |||||||||
| NPI: | 1649777624 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARLOS | ||||||||
| FirstName: | PAMMELI | ||||||||
| MiddleName: | M. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1950 S SUNWEST LN | ||||||||
| Address2: | |||||||||
| City: | SAN BERNARDINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 924083258 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9092524010 | ||||||||
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| Practice Location | |||||||||
| Address1: | 11951 HESPERIA RD | ||||||||
| Address2: | |||||||||
| City: | HESPERIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923451855 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7609562345 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/06/2018 | ||||||||
| LastUpdateDate: | 06/08/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 1041C0700X | 91003 | CA | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 101YM0800X | CA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.