=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366749749
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HINZE PSYCHOLOGICAL SERVICES, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/19/2011
-----------------------------------------------------
Last Update Date | 01/06/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16542 VENTURA BLVD SUITE 402
-----------------------------------------------------
City | ENCINO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91436-2005
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-788-2400
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 642507
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90064-8150
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/CLINICAL PSYCHOLOGIST
-----------------------------------------------------
Name | DR. JASON HEATH HINZE
-----------------------------------------------------
Credential | PSY.D.
-----------------------------------------------------
Telephone | 310-614-3795
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | PSY23840
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------