Basic Information
| Provider Information | |||||||||
| NPI: | 1063565745 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PSYCHOTHERAPY INSTITUTE OF INDIVIDUAL, FAMILY & COMMUNITY DEVELOPMENT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 509 W 10TH ST | ||||||||
| Address2: | |||||||||
| City: | ANTIOCH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945091653 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9257779540 | ||||||||
| FaxNumber: | 9257579024 | ||||||||
| Practice Location | |||||||||
| Address1: | 509 W 10TH ST | ||||||||
| Address2: | |||||||||
| City: | ANTIOCH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945091653 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9257779540 | ||||||||
| FaxNumber: | 9257579024 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | ROBINSON | ||||||||
| AuthorizedOfficialFirstName: | WESLEY | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9257779540 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | PH.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | PSY15066 | CA | X | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TC2200X | PSY15066 | CA | X | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent | 103T00000X | PSY15066 | CA | X | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.