Provider Demographics
NPI:1407063936
Name:HIAWATHA HARRIS, CORPORATION
Entity Type:Organization
Organization Name:HIAWATHA HARRIS, CORPORATION
Other - Org Name:PATHWAYS TO WELLNESS MEDICATION CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:C.E.O.
Authorized Official - Prefix:
Authorized Official - First Name:NEISHA
Authorized Official - Middle Name:
Authorized Official - Last Name:BECTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:925-520-0005
Mailing Address - Street 1:5674 STONERIDGE DR
Mailing Address - Street 2:SUITE 207
Mailing Address - City:PLEASANTON
Mailing Address - State:CA
Mailing Address - Zip Code:94588-8500
Mailing Address - Country:US
Mailing Address - Phone:925-520-0005
Mailing Address - Fax:925-520-0010
Practice Address - Street 1:1210 ALHAMBRA AVE
Practice Address - Street 2:
Practice Address - City:MARTINEZ
Practice Address - State:CA
Practice Address - Zip Code:94553-2314
Practice Address - Country:US
Practice Address - Phone:925-520-0005
Practice Address - Fax:925-520-0010
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-16
Last Update Date:2011-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC22371103TC2200X, 103TF0000X, 103TM1800X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Multi-Specialty
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamilyGroup - Multi-Specialty
No103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental DisabilitiesGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty