Basic Information
| Provider Information | |||||||||
| NPI: | 1912235573 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | VICTOR VALLEY COUNSELING CENTER, MENTAL HEALTH COURT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 303 E VANDERBILT WAY | ||||||||
| Address2: | |||||||||
| City: | SAN BERNARDINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 924150026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9093880801 | ||||||||
| FaxNumber: | 9098900435 | ||||||||
| Practice Location | |||||||||
| Address1: | 12625 HESPERIA RD | ||||||||
| Address2: | |||||||||
| City: | VICTORVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923957720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9093823080 | ||||||||
| FaxNumber: | 9093823105 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/19/2009 | ||||||||
| LastUpdateDate: | 06/18/2019 | ||||||||
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| AuthorizedOfficialLastName: | PORTEOUS | ||||||||
| AuthorizedOfficialFirstName: | ERICA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF COMPLIANCE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 9093880882 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | COUNTY OF SAN BERNARDINO | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0850X | Y | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health |
No ID Information.