Provider Demographics
NPI:1013624121
Name:HEART AND SOUL COLLABORATIVE
Entity Type:Organization
Organization Name:HEART AND SOUL COLLABORATIVE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:HOOPER
Authorized Official - Suffix:
Authorized Official - Credentials:MPH,CHES
Authorized Official - Phone:951-255-1510
Mailing Address - Street 1:19069 VAN BUREN BLVD STE 114-431
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92508-9169
Mailing Address - Country:US
Mailing Address - Phone:951-255-1510
Mailing Address - Fax:
Practice Address - Street 1:7000 INDIANA AVE STE 114
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-4155
Practice Address - Country:US
Practice Address - Phone:951-255-1510
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-31
Last Update Date:2022-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty