Provider Demographics
NPI:1265301303
Name:GENTLE ROOTS THERAPEUTIC SERVICES, LICENSED CLINICAL SOCIAL WORKER, AP
Entity type:Organization
Organization Name:GENTLE ROOTS THERAPEUTIC SERVICES, LICENSED CLINICAL SOCIAL WORKER, AP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LCSW
Authorized Official - Prefix:
Authorized Official - First Name:SHAREELA
Authorized Official - Middle Name:
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-688-6604
Mailing Address - Street 1:1519 N LILAC AVE
Mailing Address - Street 2:
Mailing Address - City:RIALTO
Mailing Address - State:CA
Mailing Address - Zip Code:92376-3274
Mailing Address - Country:US
Mailing Address - Phone:909-688-6604
Mailing Address - Fax:
Practice Address - Street 1:7365 CARNELIAN ST STE 224
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-1157
Practice Address - Country:US
Practice Address - Phone:909-688-6604
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-11-04
Last Update Date:2025-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty