Healthcare Provider Details

I. General information

NPI: 1689851669
Provider Name (Legal Business Name): SIMPLICITY OF HEART COUNSELING SERVICE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2008
Last Update Date: 01/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 CEDAR AVENUE
ATWATER CA
95301
US

IV. Provider business mailing address

1201 CEDAR AVENUE
ATWATER CA
95301
US

V. Phone/Fax

Practice location:
  • Phone: 209-357-3220
  • Fax: 209-357-3220
Mailing address:
  • Phone: 209-357-3220
  • Fax: 209-357-3220

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberR0979347
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberR0979347
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberR0979347
License Number StateCA

VIII. Authorized Official

Name: MANUEL C REYES
Title or Position: CEO
Credential: MFT PHD
Phone: 209-357-3220