Provider Demographics
NPI:1376681163
Name:HERITAGE CLINIC AND THE COMMUNITY ASSISTANCE PROGRAM FOR SENIORS
Entity Type:Organization
Organization Name:HERITAGE CLINIC AND THE COMMUNITY ASSISTANCE PROGRAM FOR SENIORS
Other - Org Name:HERITAGE CLINIC & COMMUNITY ASSISTANCE PROGRAMS FOR SENIORS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMIE
Authorized Official - Middle Name:
Authorized Official - Last Name:GARIS
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:626-577-8480
Mailing Address - Street 1:447 N EL MOLINO AVE
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91101-1403
Mailing Address - Country:US
Mailing Address - Phone:626-577-8480
Mailing Address - Fax:626-577-8978
Practice Address - Street 1:3939 ATLANTIC AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90807-3536
Practice Address - Country:US
Practice Address - Phone:562-264-6001
Practice Address - Fax:562-264-6006
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-02
Last Update Date:2022-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY17307103TC0700X
171M00000X, 251X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
No251X00000XAgenciesSupports BrokerageGroup - Multi-Specialty