Basic Information
| Provider Information | |||||||||
| NPI: | 1376681163 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HERITAGE CLINIC AND THE COMMUNITY ASSISTANCE PROGRAM FOR SENIORS | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | HERITAGE CLINIC & COMMUNITY ASSISTANCE PROGRAMS FOR SENIORS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 447 N EL MOLINO AVE | ||||||||
| Address2: | |||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911011403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6265778480 | ||||||||
| FaxNumber: | 6265778978 | ||||||||
| Practice Location | |||||||||
| Address1: | 3939 ATLANTIC AVE | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | LONG BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 908073536 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5622646001 | ||||||||
| FaxNumber: | 5622646006 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/02/2007 | ||||||||
| LastUpdateDate: | 02/17/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| AuthorizedOfficialLastName: | GARIS | ||||||||
| AuthorizedOfficialFirstName: | JAMIE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PROGRAM DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6265778480 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | PSY.D. | ||||||||
| NPICertificationDate: | 02/17/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | N | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Case Manager/Care Coordinator | 251X00000X | N | Agencies | Supports Brokerage | 103TC0700X | PSY17307 | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.