Healthcare Provider Details

I. General information

NPI: 1598365652
Provider Name (Legal Business Name): HEARTS FOR SIGHT FOUNDATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/28/2020
Last Update Date: 10/28/2020
Certification Date: 10/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1540 PROSPECT AVE APT A
SAN GABRIEL CA
91776-4484
US

IV. Provider business mailing address

1540 PROSPECT AVE APT A
SAN GABRIEL CA
91776-4484
US

V. Phone/Fax

Practice location:
  • Phone: 760-443-8430
  • Fax:
Mailing address:
  • Phone: 760-443-8430
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. JOSEPH WILLIAM BURTON
Title or Position: BOARD PRESIDENT AND CEO
Credential: MSW CANIDATE
Phone: 760-433-8430