=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275669475
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GRAND TERRACE PSYCHOLOGICAL SERVICES, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/24/2007
-----------------------------------------------------
Last Update Date | 06/12/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 721 NEVADA ST STE 203
-----------------------------------------------------
City | REDLANDS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92373-8051
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-798-5669
-----------------------------------------------------
Fax | 909-335-9219
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | POST OFFICE BOX 950
-----------------------------------------------------
City | RANCHO CUCAMONGA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91729
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-899-6800
-----------------------------------------------------
Fax | 909-899-6884
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. EDWARD B PFLAUMER
-----------------------------------------------------
Credential | PH.D.
-----------------------------------------------------
Telephone | 909-899-6800
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | PSY10385
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------