Provider Demographics
NPI:1982823944
Name:BANTUM, ALFREDA YVONNE (MS)
Entity Type:Individual
Prefix:MS
First Name:ALFREDA
Middle Name:YVONNE
Last Name:BANTUM
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20426 TOBIRA LN
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92508-3030
Mailing Address - Country:US
Mailing Address - Phone:951-756-9637
Mailing Address - Fax:
Practice Address - Street 1:1505 W HIGHLAND AVE STE 17
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92411-1215
Practice Address - Country:US
Practice Address - Phone:909-880-9130
Practice Address - Fax:909-473-1918
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-25
Last Update Date:2013-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA251S00000X
CA55644101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No251S00000XAgenciesCommunity/Behavioral Health