Provider Demographics
NPI:1275669475
Name:GRAND TERRACE PSYCHOLOGICAL SERVICES, INC.
Entity Type:Organization
Organization Name:GRAND TERRACE PSYCHOLOGICAL SERVICES, INC.
Other - Org Name:CALIFORNIA BEHAVIORAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:B
Authorized Official - Last Name:PFLAUMER
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:909-899-6800
Mailing Address - Street 1:POST OFFICE BOX 950
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91729
Mailing Address - Country:US
Mailing Address - Phone:909-899-6800
Mailing Address - Fax:909-899-6884
Practice Address - Street 1:721 NEVADA ST STE 203
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373-8051
Practice Address - Country:US
Practice Address - Phone:909-798-5669
Practice Address - Fax:909-335-9219
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-24
Last Update Date:2012-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY10385103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGPS001160Medicaid
CAPSY10385OtherLICENSE NUMBER
R23610Medicare UPIN
CA0PL103850Medicare ID - Type UnspecifiedMEDICARE PROVIDER