Provider Demographics
NPI:1548771132
Name:EMPIRE BEHAVIORAL HEALTH A PSYCHOLOGICAL CORPORATION
Entity type:Organization
Organization Name:EMPIRE BEHAVIORAL HEALTH A PSYCHOLOGICAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHD
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:SCHNOSE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:909-725-4742
Mailing Address - Street 1:PO BOX 2295
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91729-2295
Mailing Address - Country:US
Mailing Address - Phone:909-725-4742
Mailing Address - Fax:909-752-9275
Practice Address - Street 1:16465 SIERRA LAKES PKWY
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92336-1242
Practice Address - Country:US
Practice Address - Phone:909-725-4742
Practice Address - Fax:909-725-4742
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-23
Last Update Date:2018-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21991103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & BehavioralGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA21991OtherLICENSE