Healthcare Provider Details

I. General information

NPI: 1407250798
Provider Name (Legal Business Name): CONNECTIONS A COUNSELING CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/15/2014
Last Update Date: 06/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39055 HASTINGS ST SUITE 106
FREMONT CA
94538-1518
US

IV. Provider business mailing address

39055 HASTINGS ST SUITE 106
FREMONT CA
94538-1518
US

V. Phone/Fax

Practice location:
  • Phone: 510-789-3368
  • Fax:
Mailing address:
  • Phone: 510-789-3368
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY 18481
License Number StateCA

VIII. Authorized Official

Name: MR. JOSHUA TAYLOR WIGGINS
Title or Position: CREDENTIALING AGENT
Credential:
Phone: 888-543-6349