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General NPI Number Information
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NPI Number | 1336532340
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Entity Type | Organization
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Legal Business Name | COLLABORATIVE PSYCHOLOGY GROUP, A PROFESSIONAL CORPORATION
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Dates
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Enumeration Date | 03/16/2015
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Last Update Date | 10/17/2020
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Provider Practice Location Address
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Address Line | 5051 CANYON CREST DR SUITE 204
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City | RIVERSIDE
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State | CA
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Zip | 92507
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Country | US
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Telephone | 951-682-1488
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Fax |
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Provider Business Mailing Address
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Address Line | 5051 CANYON CREST DR SUITE 204
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City | RIVERSIDE
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State | CA
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Zip | 92507-6099
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER/CEO
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Name | TANIKA GAYLE
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Credential | PSY. D
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Telephone | 951-682-1488
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | PSY 23903
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number |
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License Number State |
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