MEDICARE: ELEVATE PSYCHOLOGICAL GROUP 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	103T00000X	Psychologist

General Provider Information

NPI Number	:	1194317750
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ELEVATE PSYCHOLOGICAL GROUP INC

Provider Business Mailing Address
First Line	:	80 WOOD RD STE 306
Second Line	:
City	:	CAMARILLO
State	:	CA
Zip	:	93010-8312
Country	:	US
Telephone Number	:	805-244-6919
Fax Number	:

Provider Business Practice Location Address
First Line	:	80 WOOD RD STE 306
Second Line	:
City	:	CAMARILLO
State	:	CA
Zip	:	93010-8312
Country	:	US
Telephone Number	:	805-244-6919
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. ROBERT EDWARD SACK
Credential	:	PHD
Telephone Number	:	805-244-6919

Provider Enumeration Date	:	02/05/2021
Last Update Date	:	02/05/2021

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