Healthcare Provider Details

I. General information

NPI: 1336121888
Provider Name (Legal Business Name): FOOTHILLS PSYCHOLOGICAL SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/18/2005
Last Update Date: 02/09/2024
Certification Date: 02/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

954 W FOOTHILL BLVD STE A
UPLAND CA
91786-3782
US

IV. Provider business mailing address

954 W FOOTHILL BLVD STE A
UPLAND CA
91786-3782
US

V. Phone/Fax

Practice location:
  • Phone: 909-946-4222
  • Fax:
Mailing address:
  • Phone: 909-946-4222
  • Fax: 909-946-8243

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: KIRTRINA JONES
Title or Position: CREDENTIALING SUPERVISOR
Credential:
Phone: 909-946-4222