Provider Demographics
NPI:1073772711
Name:VILLAGE COUNSELING & ASSESSMENT CENTER A PSYCHOLOGICAL SERVICES CLINIC
Entity type:Organization
Organization Name:VILLAGE COUNSELING & ASSESSMENT CENTER A PSYCHOLOGICAL SERVICES CLINIC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:AHMED
Authorized Official - Middle Name:M
Authorized Official - Last Name:DARWISH
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD, JD
Authorized Official - Phone:510-339-8221
Mailing Address - Street 1:1955 MOUNTAIN BLVD
Mailing Address - Street 2:STE 111
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94611-2830
Mailing Address - Country:US
Mailing Address - Phone:510-339-8221
Mailing Address - Fax:510-339-8223
Practice Address - Street 1:1955 MOUNTAIN BLVD
Practice Address - Street 2:STE 111
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94611-2830
Practice Address - Country:US
Practice Address - Phone:510-339-8221
Practice Address - Fax:510-339-8223
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-06
Last Update Date:2015-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY20965103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY20965Medicare PIN