Basic Information
| Provider Information | |||||||||
| NPI: | 1538556865 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TLC BEHAVIORAL HEALTH AND PSYCHOLOGY CORPORATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1080 MARINA VILLAGE PARKWAY | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | ALAMEDA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945011078 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5103377950 | ||||||||
| FaxNumber: | 5103377969 | ||||||||
| Practice Location | |||||||||
| Address1: | 1080 MARINA VILLAGE PARKWAY | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | ALAMEDA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945011078 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5103377950 | ||||||||
| FaxNumber: | 5103377969 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/24/2015 | ||||||||
| LastUpdateDate: | 05/10/2016 | ||||||||
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| AuthorizedOfficialLastName: | WIEDERSTEIN | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO, CFO | ||||||||
| AuthorizedOfficialTelephone: | 5103377950 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TH0100X | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Health Service |
No ID Information.