Healthcare Provider Details

I. General information

NPI: 1013624121
Provider Name (Legal Business Name): HEART AND SOUL COLLABORATIVE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/31/2022
Last Update Date: 10/31/2022
Certification Date: 10/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7000 INDIANA AVE STE 114
RIVERSIDE CA
92506-4155
US

IV. Provider business mailing address

19069 VAN BUREN BLVD STE 114-431
RIVERSIDE CA
92508-9169
US

V. Phone/Fax

Practice location:
  • Phone: 951-255-1510
  • Fax:
Mailing address:
  • Phone: 951-255-1510
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State

VIII. Authorized Official

Name: RYAN HOOPER
Title or Position: CEO/EXECUTIVE DIRECTOR
Credential: M.P.H.,CHES
Phone: 951-255-1510