MEDICARE: HEALING STRIDES PSYCHOTHERAPY, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC1900X	Counseling Psychologist	PSY27263	CA

General Provider Information

NPI Number	:	1124400155
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HEALING STRIDES PSYCHOTHERAPY, INC.

Provider Business Mailing Address
First Line	:	PO BOX 1006
Second Line	:
City	:	BLUE LAKE
State	:	CA
Zip	:	95525-1006
Country	:	US
Telephone Number	:	707-845-8737
Fax Number	:

Provider Business Practice Location Address
First Line	:	PO BOX 1006
Second Line	:
City	:	BLUE LAKE
State	:	CA
Zip	:	95525-1006
Country	:	US
Telephone Number	:	707-845-8737
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. TERRI ELANA JENNINGS
Credential	:	PH.D.
Telephone Number	:	707-845-8737

Provider Enumeration Date	:	06/26/2015
Last Update Date	:	08/19/2019

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