Provider Demographics
NPI:1346781465
Name:SAN BERNARDINO CONTY
Entity Type:Organization
Organization Name:SAN BERNARDINO CONTY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL SUPERVISOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MATTY
Authorized Official - Middle Name:
Authorized Official - Last Name:LANDA
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:760-243-8140
Mailing Address - Street 1:15480 RAMONA AVE
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92392-2421
Mailing Address - Country:US
Mailing Address - Phone:760-243-8261
Mailing Address - Fax:
Practice Address - Street 1:15480 RAMONA AVE.
Practice Address - Street 2:
Practice Address - City:VICTOVILLE
Practice Address - State:CA
Practice Address - Zip Code:92392
Practice Address - Country:US
Practice Address - Phone:760-243-8261
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-09
Last Update Date:2017-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YM0800X
101YM0800X, 251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty