Provider Demographics
NPI:1689031528
Name:INLAND EMPIRE AUTISM SPECTRUM DISORDER ASSESSMENT CENTER OF EXCELLENCE
Entity Type:Organization
Organization Name:INLAND EMPIRE AUTISM SPECTRUM DISORDER ASSESSMENT CENTER OF EXCELLENCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ZACHARY
Authorized Official - Middle Name:DANE
Authorized Official - Last Name:GINDER
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD, MSW
Authorized Official - Phone:909-799-3777
Mailing Address - Street 1:1499 S TIPPECANOE AVE BLDG A
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92408-2920
Mailing Address - Country:US
Mailing Address - Phone:909-799-3777
Mailing Address - Fax:909-799-5999
Practice Address - Street 1:1499 S TIPPECANOE AVE BUILDING A
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92415-0024
Practice Address - Country:US
Practice Address - Phone:909-799-3777
Practice Address - Fax:909-799-5999
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-22
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY24993103G00000X
CAPSY15160103T00000X
CAPSY23181103T00000X
CAPSY25134103T00000X
CAG46919174400000X
CAA118211174400000X
CAA239458174400000X
CA2683225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty