Healthcare Provider Details

I. General information

NPI: 1396021150
Provider Name (Legal Business Name): HIAWATHA HARRIS, CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2011
Last Update Date: 10/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

509 W 10TH ST
ANTIOCH CA
94509-1653
US

IV. Provider business mailing address

5674 STONERIDGE DR STE 207
PLEASANTON CA
94588-8592
US

V. Phone/Fax

Practice location:
  • Phone: 925-706-1510
  • Fax: 925-892-9822
Mailing address:
  • Phone: 925-520-0005
  • Fax: 925-520-0010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code103TP0016X
TaxonomyPrescribing (Medical) Psychologist
License Number
License Number State

VIII. Authorized Official

Name: MRS. NEISHA BECTON
Title or Position: CEO
Credential:
Phone: 925-520-0005