=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083989024
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DEL SOL PSYCHOLOGYCAL CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/08/2012
-----------------------------------------------------
Last Update Date | 03/08/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 397 N CENTRAL AVE
-----------------------------------------------------
City | UPLAND
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91786-4217
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-608-9222
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 397 N CENTRAL AVE
-----------------------------------------------------
City | UPLAND
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91786-4217
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-608-9222
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINICAL DIRECTOR
-----------------------------------------------------
Name | DR. JULIETA M CALDERON
-----------------------------------------------------
Credential | MFT, PSY.D
-----------------------------------------------------
Telephone | 909-608-9222
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 302R00000X
-----------------------------------------------------
Taxonomy Name | Health Maintenance Organization
-----------------------------------------------------
License Number | 27904
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------