Healthcare Provider Details

I. General information

NPI: 1104463371
Provider Name (Legal Business Name): HIGH DESERT PSYCHOLOGICAL SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2019
Last Update Date: 10/27/2020
Certification Date: 10/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15497 W SAND ST
VICTORVILLE CA
92392-2910
US

IV. Provider business mailing address

15497 W SAND ST
VICTORVILLE CA
92392-2910
US

V. Phone/Fax

Practice location:
  • Phone: 442-327-9311
  • Fax: 442-327-9315
Mailing address:
  • Phone: 442-327-9311
  • Fax: 442-327-9315

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name: ERIC BAHRA
Title or Position: OWNER
Credential: LCSW
Phone: 714-290-3009