Provider Demographics
NPI:1811314602
Name:IDEAL LIVING PSYCHOLOGY CENTER
Entity type:Organization
Organization Name:IDEAL LIVING PSYCHOLOGY CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT, CEO
Authorized Official - Prefix:
Authorized Official - First Name:RAKESHIA
Authorized Official - Middle Name:
Authorized Official - Last Name:BREAUX
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:909-758-1743
Mailing Address - Street 1:9220 HAVEN AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-8551
Mailing Address - Country:US
Mailing Address - Phone:909-758-1743
Mailing Address - Fax:909-758-1708
Practice Address - Street 1:9220 HAVEN AVE STE 100
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730
Practice Address - Country:US
Practice Address - Phone:909-758-1743
Practice Address - Fax:909-758-1708
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-18
Last Update Date:2025-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA41719106H00000X
106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty