Basic Information
| Provider Information | |||||||||
| NPI: | 1396021150 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HIAWATHA HARRIS, CORPORATION | ||||||||
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| OtherOrganizationName: | PATHWAYS TO WELLNESS, MEDICATION CLINIC | ||||||||
| 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: | 509 W 10TH ST | ||||||||
| Address2: | |||||||||
| City: | ANTIOCH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945091653 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9257061510 | ||||||||
| FaxNumber: | 9258929822 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2011 | ||||||||
| LastUpdateDate: | 10/25/2011 | ||||||||
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| AuthorizedOfficialLastName: | BECTON | ||||||||
| AuthorizedOfficialFirstName: | NEISHA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9255200005 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health | 103TC0700X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TP0016X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Prescribing (Medical) |
No ID Information.