1275669475 NPI number — GRAND TERRACE PSYCHOLOGICAL SERVICES, INC.

Table of content: (NPI 1275669475)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275669475 NPI number — GRAND TERRACE PSYCHOLOGICAL SERVICES, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GRAND TERRACE PSYCHOLOGICAL SERVICES, 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:
6
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:
1275669475
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/12/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
POST OFFICE BOX 950
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RANCHO CUCAMONGA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91729
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-899-6800
Provider Business Mailing Address Fax Number:
909-899-6884

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
721 NEVADA ST STE 203
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
REDLANDS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92373-8051
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-798-5669
Provider Business Practice Location Address Fax Number:
909-335-9219
Provider Enumeration Date:
02/24/2007

Additional Information

Authorized Official

Authorized Official Last Name:
PFLAUMER
Authorized Official First Name:
EDWARD
Authorized Official Middle Name:
B
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
909-899-6800

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X , with the licence number:  PSY10385 , 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)

  • Identifier: GPS001160 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: PSY10385 . This is a "LICENSE NUMBER" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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