Provider Demographics
NPI:1740472422
Name:PACIFIC FORENISC PSYCHOLOGY
Entity type:Organization
Organization Name:PACIFIC FORENISC PSYCHOLOGY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:STEWART
Authorized Official - Last Name:CUNNINGHAM
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:909-783-1473
Mailing Address - Street 1:1025 S MOUNT VERNON AVE STE A
Mailing Address - Street 2:
Mailing Address - City:COLTON
Mailing Address - State:CA
Mailing Address - Zip Code:92324-4226
Mailing Address - Country:US
Mailing Address - Phone:909-783-1473
Mailing Address - Fax:909-783-6717
Practice Address - Street 1:1025 S MOUNT VERNON AVE STE A
Practice Address - Street 2:
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-4226
Practice Address - Country:US
Practice Address - Phone:909-783-1473
Practice Address - Fax:909-783-6717
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-15
Last Update Date:2007-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty