Provider Demographics
NPI:1407369317
Name:CITY OF THE HEART PSYCHOLOGICAL SERVICE, A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:CITY OF THE HEART PSYCHOLOGICAL SERVICE, A PROFESSIONAL CORPORATION
Other - Org Name:CITY OF THE HEART PSYCHOLOGICAL SERVICES, INC.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:WOLFGANG
Authorized Official - Middle Name:ANGELUS
Authorized Official - Last Name:KLEBEL
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:951-928-6326
Mailing Address - Street 1:41580 AVENIDA BARCA
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92591-1561
Mailing Address - Country:US
Mailing Address - Phone:951-623-9358
Mailing Address - Fax:951-344-8363
Practice Address - Street 1:623 E LATHAM AVE
Practice Address - Street 2:
Practice Address - City:HEMET
Practice Address - State:CA
Practice Address - Zip Code:92543-4342
Practice Address - Country:US
Practice Address - Phone:951-928-6326
Practice Address - Fax:951-344-8353
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-14
Last Update Date:2023-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY6005103TC0700X
106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA33-BEHSMedicaid