Provider Demographics
NPI:1669717922
Name:REDLANDS PSYCHOLOGICAL SERVICES
Entity type:Organization
Organization Name:REDLANDS PSYCHOLOGICAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:
Authorized Official - Last Name:POTTS
Authorized Official - Suffix:
Authorized Official - Credentials:MDIV, PHD
Authorized Official - Phone:909-904-4462
Mailing Address - Street 1:104 E OLIVE AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-5255
Mailing Address - Country:US
Mailing Address - Phone:909-327-2735
Mailing Address - Fax:909-327-2735
Practice Address - Street 1:104 E OLIVE AVE STE 100
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373-5255
Practice Address - Country:US
Practice Address - Phone:909-327-2735
Practice Address - Fax:909-327-2735
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-27
Last Update Date:2015-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 23630103TP0814X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No103TP0814XBehavioral Health & Social Service ProvidersPsychologistPsychoanalysisGroup - Multi-Specialty