1073755401 NPI number — CONCEPT HEALTHCARE PSYCHOLOGY GROUP, INC.

Table of content: (NPI 1073755401)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073755401 NPI number — CONCEPT HEALTHCARE PSYCHOLOGY GROUP, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CONCEPT HEALTHCARE PSYCHOLOGY GROUP, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1073755401
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/31/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4901 MORENA BLVD
Provider Second Line Business Mailing Address:
SUITE 109
Provider Business Mailing Address City Name:
SAN DIEGO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92117-3423
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
858-272-3992
Provider Business Mailing Address Fax Number:
858-272-3804

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1717 W STETSON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HEMET
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92545-6882
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
951-925-9171
Provider Business Practice Location Address Fax Number:
951-925-8186
Provider Enumeration Date:
03/31/2009

Additional Information

Authorized Official

Authorized Official Last Name:
CASCIANI
Authorized Official First Name:
JOSEPH
Authorized Official Middle Name:
M
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
858-272-3992

Provider Taxonomy Codes

  • Taxonomy code: 103TH0100X , with the licence number:  PSY5291 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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