Basic Information
| Provider Information | |||||||||
| NPI: | 1073942678 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HIAWATHA HARRIS, M.D., INC. | ||||||||
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| OtherOrganizationName: | PATHWAYS TO WELLNESS MEDICATION CLINICS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5674 STONERIDGE DR STE 207 | ||||||||
| Address2: | |||||||||
| City: | PLEASANTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945888592 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9255200005 | ||||||||
| FaxNumber: | 9255200010 | ||||||||
| Practice Location | |||||||||
| Address1: | 5674 STONERIDGE DR STE 119 | ||||||||
| Address2: | |||||||||
| City: | PLEASANTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945888536 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9255200005 | ||||||||
| FaxNumber: | 9255200010 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2013 | ||||||||
| LastUpdateDate: | 11/04/2013 | ||||||||
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| AuthorizedOfficialLastName: | HURSKIN | ||||||||
| AuthorizedOfficialFirstName: | CEDRIC | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF OPERATING OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 9255200005 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | 106H00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 2084P0804X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry | 2084P0800X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.