=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861716854
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PROFESSIONAL ASSESSMENT AND TREATMENT SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/18/2010
-----------------------------------------------------
Last Update Date | 03/18/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12204 N MAINSTREET #1
-----------------------------------------------------
City | RANCHO CUCAMONGA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91739-8691
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-665-7354
-----------------------------------------------------
Fax | 909-803-0384
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12204 N MAINSTREET #1
-----------------------------------------------------
City | RANCHO CUCAMONGA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91739-8691
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-665-7354
-----------------------------------------------------
Fax | 909-803-0384
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. AURELIO J ENRIQUEZ JR.
-----------------------------------------------------
Credential | LCSW, PSYD
-----------------------------------------------------
Telephone | 626-665-7354
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | LCS 24862
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------