=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285073767
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BUSINESS CONSULTATION AND MANAGEMENT SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/18/2013
-----------------------------------------------------
Last Update Date | 06/18/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 250 W 1ST ST
-----------------------------------------------------
City | CLAREMONT
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91711-4736
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-263-5799
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 492
-----------------------------------------------------
City | CLAREMONT
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91711-0492
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PSYCHOLOGIST/ CONSULTANT
-----------------------------------------------------
Name | DR. MARISSA LONG
-----------------------------------------------------
Credential | M.A.O.B., PSY.D.
-----------------------------------------------------
Telephone | 909-263-5799
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | PSY24675
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------