Provider Demographics
NPI:1194454546
Name:LIBERTY PSYCHIATRY AND MENTAL HEALTH A PROFESSIONAL NURSING CORP
Entity Type:Organization
Organization Name:LIBERTY PSYCHIATRY AND MENTAL HEALTH A PROFESSIONAL NURSING CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:OLUWATOYIN
Authorized Official - Middle Name:
Authorized Official - Last Name:OGUNJALE
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:909-635-5627
Mailing Address - Street 1:6833 INDIANA AVE STE 208
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506-4223
Mailing Address - Country:US
Mailing Address - Phone:909-635-5627
Mailing Address - Fax:
Practice Address - Street 1:6833 INDIANA AVE STE 208
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-4223
Practice Address - Country:US
Practice Address - Phone:909-635-5627
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-09
Last Update Date:2022-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty