Provider Demographics
NPI:1972096295
Name:MENTAL WELLNESS PARTNERS
Entity type:Organization
Organization Name:MENTAL WELLNESS PARTNERS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER/CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:PERCIVAL
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:BALDRIAS
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:909-920-3171
Mailing Address - Street 1:14617 WESTFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:CHINO
Mailing Address - State:CA
Mailing Address - Zip Code:91710-1303
Mailing Address - Country:US
Mailing Address - Phone:909-203-3523
Mailing Address - Fax:
Practice Address - Street 1:820 N MOUNTAIN AVE STE 215
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-4163
Practice Address - Country:US
Practice Address - Phone:909-920-3171
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-11
Last Update Date:2018-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A122142084P0800X
CANP16510363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty