=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720289366
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HEALTH GROUP PSYCHOLOGICAL SERVICES, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/30/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8580 UTICA AVE SUITE 200
-----------------------------------------------------
City | RANCHO CUCAMONGA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91730-4870
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-944-1717
-----------------------------------------------------
Fax | 909-948-5199
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8580 UTICA AVE SUITE 200
-----------------------------------------------------
City | RANCHO CUCAMONGA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91730-4870
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-944-1717
-----------------------------------------------------
Fax | 909-948-5199
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | THERAPIST OWNER
-----------------------------------------------------
Name | DR. AMY M MILLER
-----------------------------------------------------
Credential | PSY.D
-----------------------------------------------------
Telephone | 909-944-1717
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | PSY10372
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------