Healthcare Provider Details

I. General information

NPI: 1336532340
Provider Name (Legal Business Name): COLLABORATIVE PSYCHOLOGY GROUP, A PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/16/2015
Last Update Date: 10/17/2020
Certification Date: 10/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5051 CANYON CREST DR SUITE 204
RIVERSIDE CA
92507
US

IV. Provider business mailing address

5051 CANYON CREST DR SUITE 204
RIVERSIDE CA
92507-6099
US

V. Phone/Fax

Practice location:
  • Phone: 951-682-1488
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY 23903
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: TANIKA GAYLE
Title or Position: OWNER/CEO
Credential: PSY. D
Phone: 951-682-1488