Provider Demographics
NPI:1245384007
Name:PSYCHOLOGICAL SERVICES, C.A.F.
Entity Type:Organization
Organization Name:PSYCHOLOGICAL SERVICES, C.A.F.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER, CONSULTANT
Authorized Official - Prefix:MS
Authorized Official - First Name:GLORIA
Authorized Official - Middle Name:DEAN
Authorized Official - Last Name:FONDREN
Authorized Official - Suffix:
Authorized Official - Credentials:LPC, LSOTP
Authorized Official - Phone:210-658-2280
Mailing Address - Street 1:8930 FOURWINDS DR STE 247
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78239-1970
Mailing Address - Country:US
Mailing Address - Phone:210-658-2280
Mailing Address - Fax:210-945-7780
Practice Address - Street 1:8930 FOURWINDS DR
Practice Address - Street 2:SUITE 247
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78239-1970
Practice Address - Country:US
Practice Address - Phone:210-658-2280
Practice Address - Fax:210-945-7780
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX16060174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1219792-02Medicaid
TX85278LOtherBCBS PROVIDER ID