Basic Information
| Provider Information | |||||||||
| NPI: | 1134558240 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CDCR | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5215 LOTUS POND WAY | ||||||||
| Address2: | |||||||||
| City: | ELK GROVE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 957574342 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9162965089 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4001 HIGHWAY 104 | ||||||||
| Address2: | |||||||||
| City: | IONE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2092744911 | ||||||||
| FaxNumber: | 2092745147 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2013 | ||||||||
| LastUpdateDate: | 11/08/2013 | ||||||||
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| AuthorizedOfficialLastName: | FANG | ||||||||
| AuthorizedOfficialFirstName: | KO | ||||||||
| AuthorizedOfficialMiddleName: | BRUCE | ||||||||
| AuthorizedOfficialTitleorPosition: | PSYCHOLOGIST | ||||||||
| AuthorizedOfficialTelephone: | 2092744911 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PH.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | PSY18841 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.