Provider Demographics
NPI:1417592916
Name:SPIRITED BY TRUTH LICENSED CLINICAL SOCIAL WORKER CORPORTATION
Entity Type:Organization
Organization Name:SPIRITED BY TRUTH LICENSED CLINICAL SOCIAL WORKER CORPORTATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ALEXANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:SAMUEL-STURGESS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:909-312-0552
Mailing Address - Street 1:3400 INLAND EMPIRE BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91764-5577
Mailing Address - Country:US
Mailing Address - Phone:909-312-0552
Mailing Address - Fax:
Practice Address - Street 1:3400 INLAND EMPIRE BLVD STE 101
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91764-5577
Practice Address - Country:US
Practice Address - Phone:909-312-0552
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-08
Last Update Date:2019-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty