Healthcare Provider Details

I. General information

NPI: 1689031528
Provider Name (Legal Business Name): INLAND EMPIRE AUTISM SPECTRUM DISORDER ASSESSMENT CENTER OF EXCELLENCE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2016
Last Update Date: 08/01/2023
Certification Date: 08/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1499 S TIPPECANOE AVE BUILDING A
SAN BERNARDINO CA
92415-0024
US

IV. Provider business mailing address

1499 S TIPPECANOE AVE BLDG A
SAN BERNARDINO CA
92408-2920
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 TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberPSY24993
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY15160
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY23181
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY25134
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberG46919
License Number StateCA
# 6
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberA118211
License Number StateCA
# 7
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberA239458
License Number StateCA
# 8
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number2683
License Number StateCA

VIII. Authorized Official

Name: ZACHARY DANE GINDER
Title or Position: EXECUTIVE DIRECTOR
Credential: PSYD, MSW
Phone: 909-799-3777