Healthcare Provider Details

I. General information

NPI: 1073819777
Provider Name (Legal Business Name): EDUCATIONAL THERAPY ASSESSMENT & SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/28/2011
Last Update Date: 01/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34590 COUNTY LINE RD SUITE 7
YUCAIPA CA
92399-5303
US

IV. Provider business mailing address

34590 COUNTY LINE RD SUITE 7
YUCAIPA CA
92399-5303
US

V. Phone/Fax

Practice location:
  • Phone: 909-795-4255
  • Fax: 909-795-4438
Mailing address:
  • Phone: 909-795-4255
  • Fax: 909-795-4438

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License Number
License Number StateCA

VIII. Authorized Official

Name: MS. DOREEN ANN SPEARMAN
Title or Position: DIRECTOR
Credential: PT
Phone: 909-795-4255