Healthcare Provider Details

I. General information

NPI: 1467005579
Provider Name (Legal Business Name): INLAND EMPIRE AUTISM ASSESSMENT CENTER, A PSYCHOLOGICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2019
Last Update Date: 08/01/2023
Certification Date: 08/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19314 JESSE LN STE 200
RIVERSIDE CA
92508-5070
US

IV. Provider business mailing address

19314 JESSE LN STE 200
RIVERSIDE CA
92508-5070
US

V. Phone/Fax

Practice location:
  • Phone: 909-799-3777
  • Fax: 909-799-5999
Mailing address:
  • Phone: 909-799-3777
  • Fax: 909-799-5999

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2080P0008X
TaxonomyPediatric Neurodevelopmental Disabilities Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number
License Number State

VIII. Authorized Official

Name: MR. ZACHARY DANE GINDER
Title or Position: AUTHORIZED REPRESENTATIVE
Credential:
Phone: 909-799-3777