Basic Information
Provider Information | |||||||||
NPI: | 1336121888 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | FOOTHILLS PSYCHOLOGICAL SERVICES, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 13193 CENTRAL AVENUE | ||||||||
Address2: | SUITE 200 | ||||||||
City: | CHINO | ||||||||
State: | CA | ||||||||
PostalCode: | 91710 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9099029111 | ||||||||
FaxNumber: | 9099029199 | ||||||||
Practice Location | |||||||||
Address1: | 13193 CENTRAL AVENUE | ||||||||
Address2: | SUITE 200 | ||||||||
City: | CHINO | ||||||||
State: | CA | ||||||||
PostalCode: | 91710 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9099029111 | ||||||||
FaxNumber: | 9099029199 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/18/2005 | ||||||||
LastUpdateDate: | 10/25/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | JONES | ||||||||
AuthorizedOfficialFirstName: | KIRTRINA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CREDENTIALING SUPERVISOR | ||||||||
AuthorizedOfficialTelephone: | 9099464222 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 103T00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist |   |
ID Information
ID | Type | State | Issuer | Description | CH4516 | 01 | CA | RAILROAD GROUP ID | OTHER |