Healthcare Provider Details

I. General information

NPI: 1942420724
Provider Name (Legal Business Name): HIAWATHA HARRIS MD INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2007
Last Update Date: 08/16/2024
Certification Date: 08/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1970 BROADWAY STE 250
OAKLAND CA
94612-2214
US

IV. Provider business mailing address

5674 STONERIDGE DR SUITE 207
PLEASANTON CA
94588-8500
US

V. Phone/Fax

Practice location:
  • Phone: 510-273-4200
  • Fax: 510-273-8340
Mailing address:
  • Phone: 925-520-0005
  • Fax: 925-520-0010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License NumberC22371
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License NumberC22371
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberC22371
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberC22371
License Number StateCA

VIII. Authorized Official

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