Healthcare Provider Details

I. General information

NPI: 1669717922
Provider Name (Legal Business Name): REDLANDS PSYCHOLOGICAL SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/27/2012
Last Update Date: 03/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 E OLIVE AVE STE 100
REDLANDS CA
92373-5255
US

IV. Provider business mailing address

104 E OLIVE AVE STE 100
REDLANDS CA
92373-5255
US

V. Phone/Fax

Practice location:
  • Phone: 909-327-2735
  • Fax: 909-327-2735
Mailing address:
  • Phone: 909-327-2735
  • Fax: 909-327-2735

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY 23630
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code103TP0814X
TaxonomyPsychoanalysis Psychologist
License NumberPSY 23630
License Number StateCA

VIII. Authorized Official

Name: DR. GLENN POTTS
Title or Position: OWNER/ PSYCHOLOGIST
Credential: M.DIV., PHD
Phone: 909-904-4462