CDCR
Organization
Active NPI
Psychologist · Ione, CA
NPI 1134558240 · NPPES record last updated Nov 8, 2013
Key facts
- NPI
- 1134558240
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Psychologist 103T00000X
- License
- PSY18841 (CA)
- Legal business name
- CDCR
- Practice address
- 4001 Highway 104
Ione, CA 95640
- Phone
- (209) 274-4911
- Fax
- (209) 274-5147
- NPI assigned
- Nov 8, 2013
- Organization subpart
- No
Authorized official
- Name
- Ko Bruce Fang, PH.D.
- Title
- Psychologist
- Phone
- (209) 274-4911
Corporate family (same tax ID) 24
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National Provider Directory
- Tax ID family
- Community Care Services (456 organizations share this tax ID)
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|
Psychologist
Group: 193400000X SINGLE SPECIALTY GROUP |
103T00000X |
PSY18841 |
CA |
Yes |
Addresses
Primary practice location
4001 Highway 104
Ione, CA 95640
Mailing address
5215 Lotus Pond Way
Elk Grove, CA 95757-4342
Phone (916) 296-5089