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General NPI Number Information
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NPI Number | 1689031528
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Entity Type | Organization
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Legal Business Name | INLAND EMPIRE AUTISM SPECTRUM DISORDER ASSESSMENT CENTER OF EXCELLENCE
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Dates
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Enumeration Date | 01/22/2016
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Last Update Date | 08/01/2023
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Provider Practice Location Address
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Address Line | 1499 S TIPPECANOE AVE BUILDING A
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City | SAN BERNARDINO
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State | CA
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Zip | 92415-0024
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Country | US
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Telephone | 909-799-3777
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Fax | 909-799-5999
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Provider Business Mailing Address
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Address Line | 1499 S TIPPECANOE AVE BLDG A
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City | SAN BERNARDINO
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State | CA
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Zip | 92408-2920
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Country | US
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Telephone | 909-799-3777
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Fax | 909-799-5999
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | ZACHARY DANE GINDER
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Credential | PSYD, MSW
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Telephone | 909-799-3777
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | PSY15160
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | PSY23181
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License Number State | CA
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Taxonomy #3
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | PSY25134
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License Number State | CA
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Taxonomy #4
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | G46919
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License Number State | CA
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Taxonomy #5
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | A118211
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License Number State | CA
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Taxonomy #6
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | A239458
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License Number State | CA
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Taxonomy #7
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Taxonomy Code | 225X00000X
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Taxonomy Name | Occupational Therapist
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License Number | 2683
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License Number State | CA
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Taxonomy #8
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Taxonomy Code | 103G00000X
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Taxonomy Name | Clinical Neuropsychologist
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License Number | PSY24993
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License Number State | CA
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