Healthcare Provider Details

I. General information

NPI: 1023547650
Provider Name (Legal Business Name): THOMAS HARVEY BEHAVIOR TECHNICIAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/07/2017
Last Update Date: 07/14/2022
Certification Date: 07/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

47825 OASIS ST
INDIO CA
92201-6950
US

IV. Provider business mailing address

47825 OASIS ST
INDIO CA
92201-6950
US

V. Phone/Fax

Practice location:
  • Phone: 909-637-5107
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberR1239030916
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: