Provider Demographics
NPI:1285031799
Name:SALEM, RAIED ESA (IMFT)
Entity Type:Individual
Prefix:MR
First Name:RAIED
Middle Name:ESA
Last Name:SALEM
Suffix:
Gender:M
Credentials:IMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7828 HAVEN AVE # 207
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-3049
Mailing Address - Country:US
Mailing Address - Phone:909-713-4777
Mailing Address - Fax:
Practice Address - Street 1:7828 HAVEN AVE # 207
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-3049
Practice Address - Country:US
Practice Address - Phone:909-713-4777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-26
Last Update Date:2015-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF78672101YM0800X
106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAIMF78672OtherBOARD OF BEHAVIORAL SCIENCES