Provider Demographics
NPI:1649085507
Name:RESTORE MENTAL WELLNESS, LICENSED CLINICAL SOCIAL WORKER, INC
Entity type:Organization
Organization Name:RESTORE MENTAL WELLNESS, LICENSED CLINICAL SOCIAL WORKER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:DIANITZA
Authorized Official - Middle Name:
Authorized Official - Last Name:MEDINA
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:562-556-1312
Mailing Address - Street 1:13502 WHITTIER BLVD # H232
Mailing Address - Street 2:
Mailing Address - City:WHITTIER
Mailing Address - State:CA
Mailing Address - Zip Code:90605-1945
Mailing Address - Country:US
Mailing Address - Phone:562-556-1312
Mailing Address - Fax:
Practice Address - Street 1:22521 SCARLET SAGE WAY
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92557-5921
Practice Address - Country:US
Practice Address - Phone:562-556-1312
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-02-10
Last Update Date:2025-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1902064074Medicaid