Healthcare Provider Details

I. General information

NPI: 1023151693
Provider Name (Legal Business Name): HIAWATHA HARRIS MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/14/2007
Last Update Date: 08/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5674 STONERIDGE DR SUITE 205
PLEASANTON CA
94588-8500
US

IV. Provider business mailing address

5674 STONERIDGE DR SUITE 207
PLEASANTON CA
94588-8500
US

V. Phone/Fax

Practice location:
  • Phone: 925-520-0005
  • Fax: 925-520-0010
Mailing address:
  • Phone: 925-520-0005
  • Fax: 925-520-0010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberC22371
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License NumberC22371
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License NumberC22371
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberC22371
License Number StateCA

VIII. Authorized Official

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