=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669717922
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | REDLANDS PSYCHOLOGICAL SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/27/2012
-----------------------------------------------------
Last Update Date | 03/26/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 104 E OLIVE AVE STE 100
-----------------------------------------------------
City | REDLANDS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92373-5255
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-327-2735
-----------------------------------------------------
Fax | 909-327-2735
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 104 E OLIVE AVE STE 100
-----------------------------------------------------
City | REDLANDS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92373-5255
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-327-2735
-----------------------------------------------------
Fax | 909-327-2735
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/ PSYCHOLOGIST
-----------------------------------------------------
Name | DR. GLENN POTTS
-----------------------------------------------------
Credential | M.DIV., PHD
-----------------------------------------------------
Telephone | 909-904-4462
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TP0814X
-----------------------------------------------------
Taxonomy Name | Psychoanalysis Psychologist
-----------------------------------------------------
License Number | PSY 23630
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | PSY 23630
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------