Provider Demographics
NPI:1710642798
Name:BELLING, KONNER MACKENZIE
Entity Type:Individual
Prefix:
First Name:KONNER
Middle Name:MACKENZIE
Last Name:BELLING
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 E. VIA VERDE AVE.
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SAN DIMAS
Mailing Address - State:CA
Mailing Address - Zip Code:91773-3505
Mailing Address - Country:US
Mailing Address - Phone:909-957-4921
Mailing Address - Fax:
Practice Address - Street 1:180 E. VIA VERDE AVE.
Practice Address - Street 2:SUITE 200
Practice Address - City:SAN DIMAS
Practice Address - State:CA
Practice Address - Zip Code:91773-3505
Practice Address - Country:US
Practice Address - Phone:909-957-4921
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-03
Last Update Date:2023-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA109893104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker