Provider Demographics
NPI:1568289106
Name:BLACK UNICORN WELLNESS SOLUTIONS
Entity type:Organization
Organization Name:BLACK UNICORN WELLNESS SOLUTIONS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:STANISHA
Authorized Official - Middle Name:THOMASINA
Authorized Official - Last Name:YORK
Authorized Official - Suffix:
Authorized Official - Credentials:LPCC
Authorized Official - Phone:909-510-1584
Mailing Address - Street 1:3610 CENTRAL AVE STE 400
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506-5907
Mailing Address - Country:US
Mailing Address - Phone:951-398-6009
Mailing Address - Fax:
Practice Address - Street 1:3610 CENTRAL AVE STE 400
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-5907
Practice Address - Country:US
Practice Address - Phone:951-398-6009
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-24
Last Update Date:2024-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health