Basic Information
| Provider Information | |||||||||
| NPI: | 1871804021 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PSYNERGY PROGRAMS, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | CIELO VISTA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 18225 HALE AVENUE | ||||||||
| Address2: | |||||||||
| City: | MORGAN HILL | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95037 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4084658280 | ||||||||
| FaxNumber: | 4084658295 | ||||||||
| Practice Location | |||||||||
| Address1: | 806 ELM AVENUE | ||||||||
| Address2: | |||||||||
| City: | GREENFIELD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 93927 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4084658280 | ||||||||
| FaxNumber: | 4084658295 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2010 | ||||||||
| LastUpdateDate: | 07/30/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | URIBE | ||||||||
| AuthorizedOfficialFirstName: | ARTURO | ||||||||
| AuthorizedOfficialMiddleName: | MEDRANO | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF OPERATION OFFI | ||||||||
| AuthorizedOfficialTelephone: | 4084658280 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PSYNERGY PROGRAMS, INC. | ||||||||
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| AuthorizedOfficialCredential: | LCSW | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 320800000X | 275202056 | CA | Y | Residential Treatment Facilities | Community Based Residential Treatment Facility, Mental Illness |
No ID Information.