Basic Information
Provider Information | |||||||||
NPI: | 1699806794 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ROMERO | ||||||||
FirstName: | CHRISTIAN | ||||||||
MiddleName: | L | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | REINOSO | ||||||||
OtherFirstName: | CHRISTIAN | ||||||||
OtherMiddleName: | L | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 850 E FOOTHILL BLVD | ||||||||
Address2: |   | ||||||||
City: | RIALTO | ||||||||
State: | CA | ||||||||
PostalCode: | 923765230 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9094219435 | ||||||||
FaxNumber: | 9094219439 | ||||||||
Practice Location | |||||||||
Address1: | 850 E FOOTHILL BLVD | ||||||||
Address2: |   | ||||||||
City: | RIALTO | ||||||||
State: | CA | ||||||||
PostalCode: | 923765230 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9094215617 | ||||||||
FaxNumber: | 9094219439 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/08/2007 | ||||||||
LastUpdateDate: | 09/08/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/08/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | MFC53592 | CA | Y |   | Behavioral Health & Social Service Providers | Marriage & Family Therapist |   |
No ID Information.