=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760561781
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JAMES MONTY HYDEN JR. PH.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/02/2006
-----------------------------------------------------
Last Update Date | 09/12/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4715 VIEWRIDGE AVE SUITE 230
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92123-1658
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-257-8715
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 615 BENEVOLENCE WAY
-----------------------------------------------------
City | CHINA SPRING
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76633-2517
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-722-2324
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TH0100X
-----------------------------------------------------
Taxonomy Name | Health Service Psychologist
-----------------------------------------------------
License Number | 22032
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 22032
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------