Basic Information
| Provider Information | |||||||||
| NPI: | 1851511638 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HIAWATHA HARRIS MD INC. | ||||||||
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| OtherOrganizationName: | PATHWAYS TO WELLNESS MEDICATION CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5674 STONERIDGE DR | ||||||||
| Address2: | SUITE 207 | ||||||||
| City: | PLEASANTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945888500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9255200005 | ||||||||
| FaxNumber: | 9255200010 | ||||||||
| Practice Location | |||||||||
| Address1: | 2608 CENTRAL AVE STE 1 | ||||||||
| Address2: | |||||||||
| City: | UNION CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945873148 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5106750600 | ||||||||
| FaxNumber: | 5106750185 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2007 | ||||||||
| LastUpdateDate: | 08/02/2011 | ||||||||
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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 | 103TF0000X | C22371 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Family | 103TM1800X | C22371 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Mental Retardation & Developmental Disabilities | 106H00000X | C22371 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 101YM0800X | C22371 | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 01AX | 05 | CA | MEDICAID |