Provider Demographics
NPI:1073843413
Name:TRUJILLO, NATHAN
Entity type:Individual
Prefix:MR
First Name:NATHAN
Middle Name:
Last Name:TRUJILLO
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1950 S SUNWEST LN STE 200
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92408-3248
Mailing Address - Country:US
Mailing Address - Phone:909-252-4044
Mailing Address - Fax:
Practice Address - Street 1:60805 29 PALMS HWY
Practice Address - Street 2:
Practice Address - City:JOSHUA TREE
Practice Address - State:CA
Practice Address - Zip Code:92252-5901
Practice Address - Country:US
Practice Address - Phone:760-228-6391
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-07
Last Update Date:2025-04-02
Deactivation Date:2014-06-09
Deactivation Code:
Reactivation Date:2023-04-25
Provider Licenses
StateLicense IDTaxonomies
390200000X, 101YM0800X
CAAWS125596104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health