MEDICARE: ACACIA PSYCHOLOGICAL CORPORATION

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	103T00000X	Psychologist

General Provider Information

NPI Number	:	1629671862
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ACACIA PSYCHOLOGICAL CORPORATION

Provider Business Mailing Address
First Line	:	281 MAGNOLIA AVE STE 300
Second Line	:
City	:	GOLETA
State	:	CA
Zip	:	93117-3608
Country	:	US
Telephone Number	:	888-699-4873
Fax Number	:	805-472-6099

Provider Business Practice Location Address
First Line	:	325 W ADAMS BLVD STE A
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90007-2659
Country	:	US
Telephone Number	:	888-699-4873
Fax Number	:	805-472-6099

Authorized Official
Title or Position	:	CEO/CO-OWNER
Name	:	HARLAN KEITH HIGGINBOTHAM
Credential	:	PSYD
Telephone Number	:	888-699-4873

Provider Enumeration Date	:	11/19/2020
Last Update Date	:	11/19/2020

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