Basic Information
| Provider Information | |||||||||
| NPI: | 1023511318 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PSYNERGY PROGRAMS, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | PSYNERGY SACRAMENTO CLINIC B | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 18225 HALE AVE | ||||||||
| Address2: | |||||||||
| City: | MORGAN HILL | ||||||||
| State: | CA | ||||||||
| PostalCode: | 950373547 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4084658280 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4616 ROOSEVELT AVE | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958204520 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9164573129 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/13/2018 | ||||||||
| LastUpdateDate: | 09/20/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | URIBE | ||||||||
| AuthorizedOfficialFirstName: | ARTURO | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT & CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 4084658280 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PSYNERGY PROGRAMS, INC. | ||||||||
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| AuthorizedOfficialCredential: | LCSW | ||||||||
| NPICertificationDate: | 09/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 22640 | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.